INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22 to 24, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on February 17, 2007.
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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
Employee # 6 did not meet counselor qualifications. For interns to be utilized in a clinical capacity they must be viewed as staff, and meet all the requirements for counselor or counselor assistant. All appropriate documentation is required if they do not meet counselor qualifications but meet at one of the counselor assistant levels.
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Plan of Correction
A complete personnel record with the appropriate staff development/training schedule was produced for employee #6 by director. This was completed within 30 days post survey.
Any additional interns/counsleor assistants will be handled in this matter and all required paperwork will be completed within the standards timeframes. |
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 were consistently documented and followed the facility's time frames in 5 out of 5 client records reviewed. All areas were not consistently documented and facility staff failed to expand on all areas in the evaluation. These areas include composite picture, coping mechanisms counselor conclusions and negative factors.
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Plan of Correction
I believe these were included, just not in the exact PA language or under the section the surveyor felt they should be. Past surveyors did not have an issue with our format. Our psychosocials are standardized electronically throughout the Glenbeigh system, therefore, I need to utilize a team approach to revise the form, which includes the assistance of our clinical director at the inpatient unit. This should be accomplished within the next 30 days. Until then, the Erie counselors will add an addendum specifically addressing the areas of deficiencies, beginning immediately. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Treatment plan updates were documented in accordance with the facility policy on a consistent basis for the IOP and Outpatient activities. The treatment plan updates in client records # 2, 3 and 5 did not consistently document the client's progress from previous goals and objectives to justify clinical decisions regarding new goals or continuation of the previously stated goals. The updates given were brief and failed to consistently document detailed information.
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Plan of Correction
Training was held with staff upon completion of the survey by Terri Ball, Program Director/Clinical Director. Treatment plan updates were reviewed and specific direction was given to counselors by Terri Ball in completing the progress updates of each objective on the treatment plan. The impression will include whether the counselor felt any knowledge was gained from the treatment plan objective and how was it demonstrated. This became effective immediately. This area will be reviewed during weekly clinical team meetings and monthly charts reviews as part of the performance improvement process, supervised by Terri Ball to ensure this deficiency does not re-occur.
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