INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 17-18, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Deerfield Center for Addictions Treatment was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on April 18, 2008.
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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
Based on review of personnel records and conversations with the Clinical Supervisor on
March 17- 18, 2008, the facility failed to provide a counselor who meets the qualifications. The counselor was hired in September 2006 with an expired addiction counselor certification. Although she has the required experience, she does not meet the educational requirements of the position. Refer to personnel record #5.
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Plan of Correction
The Program Director will work with the employee to become recertified as an Associate Addictions Counselor I while at the same time developing a training plan for this employee to obtain her recertification as a Certified Addictions Counselor. The employee will submit a recertification application for the AAC I within the next three weeks. The Program Director will work with the employee to develop the appropriate training plan within the next two weeks. |
709.28(c) 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:
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Observations
Based on client record reviews on March 18, 2008, the facility failed to provide a signed release form prior to the disclosure of information to the Juvenile Probation Department. In addition, the information disclosed on the progress report was in excess of the limitations imposed at 4 Pa. Code Subsection 255.5(b). This was documented in one of five client records reviewed. Refer to client record #5.
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Plan of Correction
The Clinical Supervisor will review with all clinical staff the regulations regarding the appropriate process to complete a release of information form. In addition, the Clinical Supervisor will go over the limitations on the type of informatiuon that can be disclosed to the Juvenile Probation Department. This will be accomplished at the next scheduled staff meeting, (within two weeks). |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on the review of the policy and procedure manual on March 17, 2008, the facility failed to provide a policy for follow-up on clients who do not successfully complete treatment.
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Plan of Correction
The Program Director will update the current follow-up policy to include a follow-up process to be used for clients that leave treatment prematurely. The policy was updated as of 03/24/2008 and will be implemented on April 1, 2008. |