INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 18-20, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Tadiso, Inc., 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 November 16, 2010.
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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 a review of personnel records and an interview with the project director, the facility failed to ensure that each counselor met the qualifications for the position in one of three personnel records.
The findings include:
On October 18, 2010, ten personnel records were reviewed. Three personnel records were required to have documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel record # 5.
Employee # 5 was hired as a counselor on January 11, 2010. Employee # 5 has a Bachelor of Arts degree in Psychology which meets the educational requirements; but does not have one year of required clinical experience. Employee # 5 does not have documentation of any clinical experience prior to her employment at the program which began on January 11, 2010.
An interview with the project director was held on October 20, 2010 at which time it was confirmed that no additional documentation was available to illustrate clinical experience for employee #5.
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Plan of Correction
Individual was erroneously hired at the counselor level. As of 11/1/10, individual is reclassified as counselor assistant by Administrative Officer. Director of Social Serivces will ensure that supervsion and hours of training since hiring date meet that of counselor assistant. (Training hours completed are at 45). Upon one year of working at Tadiso Inc, individual will meet the one year of clinical service and be promoted to counselor position on January 15, 2011. |
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 a review of client records and an interview with the project director, the facility failed to document an informed and voluntary consent from the client for disclosure of information that indicated the specific information to be disclosed and the purpose of disclosure in fifteen of eighteen client records.
The findings include:
Twenty six client records were reviewed on October 18-20, 2010. Eighteen client records required an informed and voluntary consent to release information from the client; including the specific information to be disclosed and the purpose of disclosure. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record; including the specific information to be disclosed and the purpose of the disclosure. The facility failed to obtain an informed and voluntary consent from the client; including the specific information to be disclosed and the purpose of disclosure in client records # 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16 and 18.
An interview with the project director was held on October 20, 2010 at which time it was confirmed that the aforementioned client records contained signed consents to release information where the sections on the purpose for the release of the information and the specific information to be released were left blank.
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Plan of Correction
The authorization forms for release of confidential informantion were not completed correctly by fiscal staff for billing reimbursement despite receiving on the job training and instructions from supervisor (CFO). Fiscal supervisor will review forms to ensure correct procedure is followed. Administrative Officer will ensure that the individual receives the required Confidentialy Training and is currently enrolled in a PCB/BDAP approved 6 hour training on 11/8/10. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document goals with timeframes in the aftercare plan in three of five client records.
The findings include:
Twenty six client records were reviewed on October 18-20, 2010. Aftercare plans were required in five client records. The facility did not document goals with timeframes in the aftercare plan in client records # 21, 22 and 25.
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Plan of Correction
The Director of Social Services will conduct training for counselors on After Care Plans to ensure that the issue of time frames is addressed and documented in the client file. The training will take place in the November Social Serive Meetings. The process should be completed and procedures implemented by December 1, 2010 |