INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 27 to June 28, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 13, 2006.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
One employee's qualifications were reviewed. It was determined that employee did not meet the staffing requirements for the position of counselor. Need to assure that all counselors meet qualifications before hiring them.
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Plan of Correction
The Licensing Team, consisting of the Executive Director, Clinical Supervisor, Associate Director, HR Manager, Criminal Justice Programs Manager, and Office Coordinator met on July 13, 2006. It was determined that, immediately, a qualified employee will be acquired for the position of counselor. This employee will be fully orientated by July 31, 2006.
In addition, a revised protocol will be put in place that if, for any reason, should the degree of any potential hire for the position of counselor be questioned as to its meeting of BDAP standards, Human Resources will contact BDAP to review the degree prior to hire to ensure that the degree is acceptable for the position. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Counselor to client ratio exceeded the maximum of 35/1 for an outpatient activity. This was as a result of one counselor who did not meet staffing qualifications being assigned a caseload.
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Plan of Correction
At the Licensing Team meeting on July 13, 2006, it was determined that, by July 31, 2006, a qualified employee will be hired for the position of counselor, thereby increasing the qualified staff complement and reducing the client to staff ratio to acceptable levels. The Clinical Supervisor, through a review of files, will continue to ensure that the client to staff ratio remains at acceptable levels. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
There was no documentation that personnel were trained to perform assigned tasks during emergencies. Training needs to occur within 7 days of hire.
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Plan of Correction
At the Licensing Team meeting on July 13, 2006, the Human Resources Manager distributed a protocol that was developed to ensure that staff are trained and oriented to their role in the event of a disaster within seven days of hire. A sign-off sheet was developed to ensure that such training and orientation is documented and will be placed in the employee's personnel file. These procedures will be reviewed and approved by the Management Team by August 31, 2006.
In addition, the Licensing Team will continually review physical plant standards to ensure full compliance with BDAP requirements. |
709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Information listed on the consent to be released to criminal justice was not specific. Phrases such as "discussing results and recommendations" was too vague and can result in the release of information that exceeds the limitations of 4 Pa. Code 255.5.
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Plan of Correction
At the Licensing Team Meeting on July 13, 2006, it was reported that the Criminal Justice Programs Manager and the Clinical Supervisor will be holding a staff training on July 27, 2006 to review all Licensing observations, regrading: consent form information, release of information, and psychosocial evaluations. Minutes from this meeting will be collected and sent physically to the facility's Licesing Specialist. |
709.28(c)(3) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The purpose for releasing was not relevant to the type of release. Criminal justice does not provide continuity of care. Need state the actual purpose for the release of information.
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Plan of Correction
At the Licensing Team Meeting on July 13, 2006, it was reported that the Criminal Justice Programs Manager and the Clinical Supervisor will be holding a staff training on July 27, 2006 to review and strengthen all Licensing observations, regrading: consent form information, release of information, and psychosocial evaluations. Minutes from this meeting will be collected and sent physically to the facility's Licesing Specialist. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations contained limited counselor impressions. There were no problems or needs of the clients identified.
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Plan of Correction
At a clinical staff meeting held on July 27, 2006, led by the Criminal Justice Program Manager and the Clinical Supervisor, it was determined that, effective immediately, the Biopsychosocial Summary will be completed as a narrative by the Counselor, rather than giving one word answers. In addition, the Counselor will write impressions that will identify the problems and needs of the client.
The Clinical Supervisor will review the files regularly to ensure that this process is being followed correctly. |
709.44(a)(1)(iii) LICENSURE Personal history
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(1) Histories, which include the following:
(iii) Personal history.
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Observations
The personal histories were generally incomplete lacking detail and specificity. The supplemented ASIs (assessment instruments) were not consistently completed. The areas of greatest concern were family history and employment history.
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Plan of Correction
On July 27, 2006, clinical staff met with the Criminal Justice Manager and Clinical Supervisor, who reviewed each section of the assessment tool with the Counselors. Immediately, Counselors will consistently complete the ASI, including recording family of origin, immediate family, family relationships, child custody, and childcare arrangements on the asessment tool. Employment history will be recorded in the assessment tool by the Counselor as well and will include: job history for the last 5 years, place of employment, type and duration, reasons for leaving, degree to which the D&A use interfered with employment, relationship and with employer/employees.
The Clinical Supervisor will review the files regularly to ensure that this practice is being followed, and that this issue does not recur. |
709.44(a)(3) LICENSURE Psychosocial evaluation
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(3) Psychosocial evaluation.
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Observations
Psychosocial evaluations contained limited counselor impressions. There were no problems or needs of the clients identified.
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Plan of Correction
On July 27, 2006, clinical staff met with the Criminal Justice Programs Manager and the Clinical Supervisor. Effective immediately, Counselors will document detailed impressions in the client's files, including identifying problems and needs of the clients.
Regular review of the client files by the Clinical Supervisor will ensure this action is taken and will help identify any issues from recurring. |