INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 25, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Harwood House 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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704.8(c) LICENSURE Full Caseload Assignment
704.8. Qualifications for the position of counselor assistant.
(c) In addition to training, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level.
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Observations
Based on a review of personnel records, the facility failed to ensure that counselor assistant's assignment of a full caseload be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level in two of two applicable records reviewed.
Employee # 5 was hired by the facility on September 1, 2019 and promoted to the position of counselor assistant on September 22, 2021. The employee received a positive assessment for full caseload on the date of hire in the counselor assistant position, prior to the required direct supervision occurring.
Employee # 6 was hired by the facility on April 2, 2019 and promoted to the position of counselor assistant on October 25, 2021. The employee received a positive assessment for full caseload on the date of hire in the counselor assistant position, prior to the required direct supervision occurring.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the clinical supervisor completing supervision of counselor assistants to be consistent with requirements of direct supervision before the assignment of a full caseload.
The clinical supervisor has been trained by the director of the program on requirements of direct supervision and close supervision of counselor assistants on 1/31/2022 during our supervision meeting by reviewing licensing alert 1-15 and PA Code 704.8. The clinical supervisor will have direct supervision for at least three months with counselor assistants before assignment of a full caseload. The clinical supervisor will maintain requirements of supervision regulations.
It is the responsibility of the clinical supervisor to ensure that all counselor assistant supervision is scheduled and documented according to supervision regulations.
It is the responsibility of the program director to ensure overall 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 a review of six personnel records, the facility failed to maintain documentation that high school level counselor assistants only counseled clients under direct observation, for at least the first three months of employment in two of two applicable records reviewed.
Employee # 5 was hired by the facility on September 1, 2019 and promoted to the position of counselor assistant on September 22, 2021. The supervision notes provided at the time of inspection did not indicate that direct observation of the provision of counseling services was a part of the supervision.
Employee # 6 was hired by the facility on April 2, 2019 and promoted to the position of counselor assistant on October 25, 2021. The supervision notes provided at the time of inspection did not indicate that direct observation of the provision of counseling services was a part of the supervision.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the clinical supervisor completing supervision of counselor assistants to be consistent with requirements of direct supervision and documentation of direct supervision for at least the first three months of employment during counseling services.
The clinical supervisor has been trained by the program director on requirements of direct supervision and close supervision of counselor assistants on 1/31/2022 during the supervision meeting by reviewing Pa Code 704.9. The clinical supervisor will have direct supervision with high school level counselor assistants during counselor services. The clinical supervisor will maintain documentation requirements of supervision regulations.
It is the responsibility of the clinical supervisor to ensure that all counselor assistant supervision is scheduled and documented according to supervision regulations.
It is the responsibility of the program director to ensure overall compliance. |
709.28 (c) (5) 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 must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of seven client records, the facility failed to ensure that informed and voluntary consent to release information forms included the dated signature of a witness in one record reviewed.
Client #1 was admitted on February 24, 2021 and discharged on April 22, 2021. The record contained informed and voluntary consent to release information forms signed by the client on February 26, 2021 to the funding source, county, a treatment provider, library, and family member that were missing the dated signature of a witness on the same date as the client.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of staff completing the admission to review with client, have client sign and staff witness (sign) all consents on the day of admission.
The program director met with the clinical supervisor and admission staff on 1/28/22 to discuss that signatures are needed on all client consents and consents need to be completed on day of admission.
The clinical supervisor will meet with the clinical team on 1/31/22 to discuss chart checks to ensure all consents are signed, dated by client and witness.
It is the responsibility of the primary counselor to review client charts during intake session.
It is the responsibility of the clinical supervisor to ensure that all consents are signed,dated and witnessed in all charts.
It is the responsibility of the program director to ensure overall compliance. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to ensure that individual treatment and rehabilitation plans included documentation of the type and frequency of treatment and rehabilitation services in two of six applicable records reviewed.
Client # 2 was admitted on April 12, 2021 and discharged on June 30, 2021. The individual treatment and rehabilitation plan signed by the client on April 22, 2021 did not include the type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on April 1, 2021 and discharged on July 14, 2021. The individual treatment and rehabilitation plan signed by the client on April 14, 2021 did not include the type and frequency of treatment and rehabilitation services.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the primary counselor to include type and frequency on all treatment plans.
The program director met with the clinical supervisor on 1/28/22 to discuss time and frequency inclusion on all treatment plans.
The clinical supervisor will meet with the clinical team on 1/31/22 to review that individual treatment plans include time and frequency on all plans.
It is the responsibility of the clinical supervisor to ensure that all treatment plans include type and frequency.
It is the responsibility of the program director to ensure overall compliance. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of seven client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 30 days in three records reviewed.
Client #5 was admitted on October 4, 2021 and was active at the time of the inspection. A treatment plan update was completed on December 17, 2021, and the next treatment plan update was due by January 17, 2022; however, the next update was not completed until January 24, 2022.
Client #6 was admitted on November 16, 2021 and was active at the time of the inspection. The comprehensive treatment plan was completed on November 30, 2021, and an update was due by December 30, 2021; however, no update was completed prior to the inspection.
Client #7 was admitted on August 20, 2021 and was active at the time of the inspection. No treatment plan updates were completed between the preliminary treatment plan on August 20, 2021, and December 9, 2021. Additionally, a treatment plan update was completed on December 14, 2021, and a treatment plan update was due on January 14, 2021; however, no subsequent update was completed prior to the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the primary counselor to review and update treatment plans every 30 days for all clients on their caseload.
The program director met with the clinical supervisor on 1/28/22 to discuss 30-day time frame for treatment plan reviews and updates.
The clinical supervisor will meet with the clinical team on 1/31/22 to review the 30-day time frame for treatment plan reviews and updates.
It is the responsibility of the clinical supervisor to ensure that treatment plan reviews and updates are completed every 30 days.
it is the responsibility of the program director to ensure overall compliance. |