INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6-8, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, St. Joseph Institute 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel employment and training records, the facility failed to ensure that the Clinical Supervisor attended the core curriculum training in Clinical Supervision.
The finding includes:
Employee records were reviewed on November 6-8, 2012. This facility employs one clinical supervisor who has less than two years of documented clinical supervision experience. The employee assumed the role of Clinical Supervisor in August 2011. The facility failed to provide documentation demonstrating that this employee received the required Clinical Supervision training as of November 8, 2012.
The finding was reviewed with the Project Director and was not disputed.
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Plan of Correction
The Clinical Supervisor completed the required training program December 3-7, 2012
This requirement has been added to the training plan for the Institute and will be reviewed annually by the President to ensure compliance. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on the review of employment and training records, the facility failed to document the required period of direct observation for one counselor assistant.
The finding includes:
Employee training and supervision records were reviewed on November 6-8, 2012. The project employed one high school level counselor assistant during the past year. This employee was hired as a counselor assistant on 5/30/2011. There was no documentation that the employee received the three months of Direct Observation as of November 8, 2012.
The finding was reviewed with the Project Director and was not disputed.
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Plan of Correction
The method of documentation in the EMR has been changed to ensure the supervision information is captured. An average of 6-9 sessions/consultations per week will qualify for supervision. The counselor assistant (who has a Masters degree) will receive their CAC designation in the near future. All course work has been completed.
The Clinical Director will audit the documentation on a monthly basis to ensure compliance. |