INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 6 - 7, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Turning Point II 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 September 2, 2009. .
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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 facility director, the facility failed to provide documentation of the qualifications for the position of counselor in one of two personnel records.
The findings include:
Three personnel records were reviewed on August 6, 2009. Two personnel records were for the position of counselor. The facility failed to provide documentation that each counselor met the required qualifications in personnel record # 2.
Employee # 2, was hired for the position of counselor on May 6, 2009. The personnel record contained an unofficial college transcript; which did not include a major and a copy of a Certified Addictions Counselor certificate which expired on May 7, 2009. The facility director reported being unable to obtain this documentation due to the counselor being on medical leave.
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Plan of Correction
Employee #2 voluntarily terminated their position on August 18 due to medical reasons and is no longer employed by the organization. Project/Facility Director will implement a personnel file retention checklist procedure to require verification of official college transcripts and degree designation. For future employees who claim Certified Addictions Counselor attainment, current Certificates will also be required. The checklist procedure will be fully in place by 9/30/2009. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, and an interview with the facility director, the facility failed to ensure that a sufficient number of staff persons were trained in CPR.
The findings include:
Three personnel records were reviewed and the facility director was interviewed on August 6, 2009. The facility director confirmed that no employees have current CPR certification. The facility director reported this was an oversight and CPR classes will be scheduled as soon as possible.
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Plan of Correction
Project/Facility Director has scheduled CPR recertification instruction for October 7, 2009. The class will be administered by the American Red Cross and be conducted by a certified CPR instructor. Registrations are confirmed for two (2) staff to attend. Full compliance will be attained by 10/8/2009. To prevent recurrence of this deficiency, Project/Facility Director will implement a personnel retention checklist procedure to require verification of current CPR certification training. The checklist procedure will be fully in place by 8/30/2009 and be monitored semi-annually by the Project/Facility Director for scheduling, as needed, of CPR recertification training. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment, in one of one personnel records.
The findings include:
Three personnel records were reviewed on August 6, 2009. One personnel record required documentation of fire extinguisher training. The facility failed to document the completion of fire extinguisher training no later than seven days from the date of employment in personnel record # 2.
Employee # 2 was hired on May 6, 2009. Employee # 2 was required to complete fire extinguisher training on or before May 13, 2009. Employee # 2 did not complete fire extinguisher training until May 21, 2009.
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Plan of Correction
Project/Facility Director will implement a personnel retention checklist procedure to require verification of Fire Extinguisher operation and training. The checklist procedure will be fully in place by 8/30/2009 and be required for new employees within 7 days of retention. Full compliance will be attained by 8/30/2009. |
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
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained upon employment to perform assigned tasks during emergencies, in one of one personnel record.
The findings include:
Three personnel records were reviewed on August 6, 2009. One personnel record required documentation of the completion of emergency training. The facility failed to document the completion of emergency training no later than seven days from the date of employment in personnel record # 2.
Employee # 2 was hired on May 6, 2009. Employee # 2 was required to complete the emergency training no later than May 13, 2009. Employee # 2 did not complete the emergency training until May 21, 2009.
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Plan of Correction
Project/Facility Director will implement a personnel retention checklist procedure to require verification of Emergency Fire Training. The checklist procedure will be fully in place by 8/30/2009 and be required for new employees within 7 days of retention. Full compliance will be attained by 8/30/2009. |