Amador County Alcohol and Drug Services Department

Summary

The Grand Jury investigated the Amador County Alcohol and Drug Services Department. The investigation resulted from a complaint.

The complaint alleged wrongdoing and management deficiencies. Some allegations involved treatment methods and materials used in counseling sessions and breaches in client confidentiality. Other allegations involved failure to comply with county policies and procedures, especially in the areas of accounting and personnel management.

The Grand Jury concluded that most of the problems are due to the failure of the Amador County Alcohol and Drug Services Coordinator to adequately supervise and evaluate the activities of the Department’s employees.

Findings

There are no mandatory standards or certifications for drug and alcohol counselors. With few exceptions, private organizations and professional associations create their own standards and certify counselors.

The majority of funding for the agency comes from a contract between the state and county. This contract provides federal funds for specific programs. The contract has numerous compliance requirements.

The trend in addiction counseling is toward professional licensing based on a combination of experience and education.

Amador County’s minimum requirements for Counselor I, II, or III do not require certification of any type.

Amador County does not require continuing education for counselors.

The Alcohol and Drug Services Coordinator uses peer review to evaluate employee performance.

The county is presently centralizing administrative activities of the Drug and Alcohol Abuse Services Department to improve client services.

Computer diskettes containing client demographic information are not stored in a secure manner.

Until recently, the Department had only one computer. Access to files was by a single password. The Department did not use individual passwords. Knowing the password, anyone could view any file. Recently the Department added several computers. Individual passwords are now used. However, no one is assigned to maintain passwords and insure security.

Federal regulations require a system to protect patient records from inappropriate disclosure. State program standards require written policy concerning maintenance and disposal of confidential records.

Inactive client records are kept in unlocked file cabinets or boxes inside an unlocked storage room.

A document used in counseling referred to a major religion and men as the instigators of centuries of abuse of women and children. An independent expert could see no therapeutic value for this document and asserted the document could be damaging.

1. Because the Department’s budget comes mostly from grants, the Department follows a program model based on compliance rather than treatment.
2. Mandatory certification of counselors is expected in the near future.
3. The minimum entrance standards for Alcohol and Drug Services counselors are not stringent enough.
4. Peer review is not acceptable as the primary means of performance evaluation.
5. Many of the problems found in the agency result from a lack of direct supervision of employees.
6. Left largely on their own, some counselors strayed from the ethical standards of their profession. Failure of the Alcohol and Drug Services Coordinator to supervise counselors resulted in the use of a clearly inappropriate and unprofessional document in treatment.
7. Storing inactive client files and diskettes in unlocked file cabinets violates federal and state confidentiality regulations.
8. Lack of an assigned computer system administrator creates the potential for files being unavailable when needed.

1. Hire an outside consultant to conduct a complete program evaluation including organizational structure, counselor competency, treatment methods, treatment plan preparation, professional ethics, training, confidentiality requirements, and record keeping.
2. Strengthen entrance standards to include minimum educational requirements. Do not allow any substitution for educational requirements.
3. Institute a continuing education program for all counselors.
4. Stop using peer review as the primary means to evaluate employee performance.
5. Change the Alcohol and Drug Services Coordinator’s duties to that of a supervising clinician overseeing clients and the counseling process.
6. Provide locked storage for all active and inactive confidential files.
7. Assign a systems administrator to maintain computer security.
8. Review client confidentiality requirements with all employees. Document such requirements in a written policy.

Comment Requirements

The Grand Jury requests that the Health and Human Services Agency respond within 60 days and the Board of Supervisors respond within 90 days from the official filing date of this report as required by Penal Code 933(c).

Authority to Investigate

Penal Code Section 925 authorizes the Grand Jury to review the operation of county government. Because of its deliberations and a vote of at least twelve members as required by Penal Code Section 916 to conduct this investigation, the Grand Jury determined the complaint warranted investigation. The investigation focused on the following areas:

• the clinical program
• client confidentiality
• compliance with county policies and procedures
• management of the Department

Method of Investigation

The Grand Jury confined its investigation to the issues alleged in the complaint. The investigation involved several committees coordinated by a steering committee. Before the steering committee could begin its work, the Grand Jury received four additional complaints from the same person.

Because of the complexity of the investigation, the Grand Jury developed a database to assist in identifying each issue. The Grand Jury interviewed the complainant to clarify each issue in the complaint.

The Grand Jury consulted an independent outside expert in alcohol and drug abuse counseling regarding currently accepted standards of practice for addiction treatment.

As the investigation progressed through each phase, the entire Grand Jury reviewed each draft report, discussed it thoroughly, and approved it in accordance with Penal Code Section 916.

The Grand Jury interviewed the following people:

• complainant
• Amador County Alcohol and Drug Services Department Coordinator
• Michael Meredith of PharmaTox Institute of Addiction Studies
• The Health and Human Services Director
• Several counselors

Background

The Grand Jury investigated the Amador County Alcohol and Drug Services Department following a complaint alleging:

• Violations of county policies
• Inappropriate behavior by employees in the agency
• Use of occult materials in counseling
• Occult activities
• Failure to maintain client confidentiality
• Harassment and unfair treatment

Because many of the issues raised in the complaint involved matters of professional standards, professional ethics, and treatment methods, the Grand Jury contacted an outside expert to help with its review of these issues.

The Amador County Alcohol and Drug Services Department is under the Amador County Health and Human Services Agency. The Department’s mission is to provide support and treatment of individuals with drug or alcohol addictions. The Alcohol and Drug Services Coordinator reports to the Director of Health and Human Services Agency. The Director of Health and Human Resources is also the Alcohol and Drug Program Administrator.

Most of the Department’s funding is from a contract between the county and the California Department of Drug and Alcohol Program. This contract provides federal and state funds for specified programs. These programs and services include:

• Drinking Driver and Drug Diversion Program
• Friday Night Live and Club Live
• Assessment, intervention, and referral
• Assessment, intervention, counseling, and referral of high risk and court referred youth in schools
• Individual, family, and group counseling
• Community and school prevention programs
• Family unity
• Alcohol, drug, and mental health dual diagnosis intake, assessment, and counseling
• Prenatal day and residential treatment for pregnant and parenting women
• Changing Echoes Residential Treatment

In the past, private groups provided drug and alcohol abuse services. As government funding of these services increased, Amador County took over as the primary provider. Employees of the predecessor agency grandfathered into the civil service system. These employees had whatever education, training, or practical experience the predecessor agency required. Two employees started as receptionists and were later promoted to counselors.

Currently, prospective employees face minimum qualifications standards established by the county. These standards are a combination of experience and training. While not a written criterion, past addiction with successful recovery is desirable.

There is no state licensing or certification for counselors; instead, several private organizations provide certification. These organizations usually represent group efforts to improve the counseling profession and to lobby for legislation related to addiction issues.

The highest standard is CAADAC (and its national counterpart, NAADAC). To receive CAADAC certification requires:

• qualifying education
• qualifying supervised experience
• completion of a oral exam
• completion of a written exam

To retain certification, a counselor must complete thirty units of qualifying continuing education each year and pass an exam every two years. Other certifying organizations have lesser requirements, although most follow the work experience/training model. Amador County does not require its counselors to meet any certification standards. The Drinking Driver counselor must meet the State of California’s certification standards.

The Grand Jury reviewed the method used to supervise and evaluate the counselors. According to the Department Director, peer review is used to rate job performance. Employees rate the performance of their peers. These evaluations form the basis of individual performance reports.

Mr. Meredith confirmed that this method of evaluation is a questionable practice. According to him, peer review creates the impression that the employees rather than management are in control and allows employees to rationalize their failure to meet treatment objectives. The preferred method is for the supervisor to set the standards.

Further, it is Mr. Meredith’s opinion that success relates to how closely the counselor comes to fulfilling the client’s treatment plan. However, this method requires a supervising clinician that participates directly in all phases of a client’s treatment plan. Without direct knowledge of each counselor’s actual work on a client-by-client basis, accurate performance evaluation is not possible.

The Alcohol and Drug Services Coordinator concentrates more on budgeting, reporting, and community relations than on clinical issues. He does not participate closely in client treatment nor does he conduct exit interviews with clients to assess treatment success. Responsibility for developing treatment plans rests with individual counselors. No one assumes the role of a supervising clinician. The lack of a supervising clinician allows counselors undo latitude in designing treatment plans and programs.

Other than occasional questionnaires, there is no routine evaluation of program effectiveness.

During its investigation, the Grand Jury reviewed a number of questionable documents. The most controversial document referred to a major religion and men in extremely negative terms. This document also had a clear reference to witchery.

The Grand Jury reviewed the document with Department staff. Initially, the writer of the document denied using it in counseling. Later the author recalled having used it with four or five friends who were also clients and shared the same spiritual interests. However, another counselor recalled seeing it used at least once in a group counseling session. The Alcohol and Drug Services Coordinator was aware of the document. He contended that the document represented a historical reference to the Middle Ages and the Crusades.

The Director of Health and Human Services also reviewed the document and determined it to be inappropriate. She cautioned the administrator about the inappropriate use of religious beliefs in government agency programs. The other documents purported to be occult were guided imagery exercises commonly used in addiction treatment.

The Grand Jury reviewed the most controversial document with Mr. Meredith and discussed the use of religion in addiction treatment. According to him, successful treatment often includes a spiritual component. However, the spiritual component is highly individualized depending on the belief system of the client. Use of non-traditional religious materials as part of individual treatment plans is common.

He also stated a preference for one belief system over another or the use of a single religious doctrine for all clients is inappropriate. In reference to the controversial document, Mr. Meredith stated it had no place in any treatment program regardless of the client’s belief system.

The complaint also alleged the use of incense, ritual chanting, and drum beating by counselors in the office and group sessions. Incense burning in the office allegedly had mystical or occult connotations. The Alcohol and Drug Services Coordinator and counselors said this was to mask odors in the building. The Director of Health and Human Services stated she had inquired into this situation on her own and received the same explanation. However, she found the practice offensive to people with allergies and ordered it ended. The county has since issued a policy regarding the use of fragrances in county offices.

The Grand Jury questioned the Alcohol and Drug Services Coordinator and counselors about drum beating and chanting. They explained that these techniques are part of the guided imagery and meditation exercises used in counseling.

The Grand Jury determined that the Department does not have a formal treatment plan format. Counselors devise their own system of recording treatment goals and achievement. According to the counselors interviewed, some plans consist of notes and scraps of paper. The Alcohol and Drug Services Coordinator does not review the treatment plans developed by staff counselors. A new state mandated treatment plan format corrects this problem.

According to the complaint, Department counselors routinely violated client confidentiality. The Grand Jury found that counselors keep active client files in locked file cabinets. Except in rare situations, counselors remove only one file at a time. The Grand Jury did find two questionable practices regarding confidentiality.

First is the practice of storing inactive files in cardboard boxes in an unlocked storeroom. Second, the single computer used by counselors lacked adequate password protection. This computer contained client demographic information.

The Department added several more computers. Each counselor now has his or her own computer. Each computer has a password. However, only the user knows their password. The Alcohol and Drug Services Coordinator does not know these passwords. There is no system administrator used to maintain computer security. Thus, it is possible for a counselor to leave the agency or be absent thereby preventing access to these files.

Federal regulations require a system to protect patient records from inappropriate disclosure. State program standards require a written policy concerning maintenance and disposal of records and require storage of records in an "appropriate confidential" manner. The Grand Jury determined the agency did not comply with the requirements of its contract with the state. Specifically, the policy and procedures required by the contract do not exist.

Contractual relationships with the state and federal agencies require the Department to report on expenditure of funds. Effort devoted to meeting administrative reporting requirements takes away from time available for clinical supervision.

The Health and Human Services Director recognizes the impact of the reporting requirements and other administrative chores on clinical services. She is consolidating the administrative activities of all agencies under her direction. This consolidation allows the Alcohol and Drug Services Coordinator more time for direct supervision and clinical activities.

The allegation of numerous administrative policy violations proved unfounded. While the Grand Jury found the Alcohol and Drug Services Coordinator’s approach to management contributed to small errors in procedure and questionable business practices, the county’s system of checks and balances caught and corrected those errors.

Supplementary Information

Department of Alcohol and Drug Programs, State of California, Directory of Alcohol & Other Drug Counselor Certifying Organizations, July 1997

Amador County Drinking Driver and Drug Diversion Program Course Outline and Related Material

Amador County Prenatal Course Outline and Related Material

Combined Negotiated Net Amount (NNA) and Drug/Medi-Cal (D/MC) Contract, Volume II Documents, FY 1997-1998

Michael Meredith, Ethics of Addition Treatment and Counseling, a course outline

Chapter 42 Code of Federal Regulations Part 2

Chris B Pascal, Revised Regulations to Protect Confidentiality of Alcohol and Drug Abuse Patient records: Overview and Summary, Alcohol, Drug Abuse, and Mental Health Administration, Department of Health and Human Services, Office of General Counsel.

Amador County Job Application Standards for Counselor I, II, and III

Various documents supplied by the complainant in support of the allegations