INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 12, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Conewago Snyder 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:
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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 eight personnel records, the facility failed to ensure one of three applicable counselors had the qualifying educational requirements for the position.
Employee #6 was hired as a counselor on December 13, 2021 and was current in that position at the time of the inspection. Employee #6 had a bachelor ' s degree in mathematics, which is not a degree that qualifies for the educational requirements of a counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director met with employee #19 to reclassify employee from counselor to counselor assistant on 7/13/2022. Employee #19 completed a new counselor assistant job description on 7/13/2022 and the completed job description has been placed in employee #19's personnel file. The Facility Director and HR Department will review all counselor qualification documentation prior to governing body approval of personnel decisions in all future counselor hires and promotions of counselor assistants to counselor, effective 7/13/2022. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drills from June 2021 until June 2022, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There was not documentation of a sleeping fire drill occurring during the twelve-month span reviewed.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Beginning at time of this Plan of Correction, 7/13/2022, the Facility Director will ensure the fire drills conducted during sleeping hours, occur within 6 months of the previous drill conducted during sleeping hours. Oversight of this process will be conducted monthly by the Facility Director and the Corporate Compliance Department. Facility Director will schedule and track all drills, including sleeping drills, on her Outlook calendar with reminders set to ensure they are completed within 6 months of one another.
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