INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 19-20, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Foundations Medical Services, LLC 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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704.9(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
One personnel record was reviewed for the counselor assistant position on October 10, 2017. The facility failed to document the provision of direct observation for employee record # 9.
Employee # 9 was hired on 4/3/17 as a Bachelor's level counselor assistant. The employee required close supervision for at least the first 6 months of employment. Weekly supervision notes were reviewed for the period of 4/7/17 - 9/19/17. The facility failed to demonstrate that weekly close supervision included an additional hour of direct observation at least once a week.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Weekly supervision notes for an employee who required close supervision were reviewed and the facility failed to demonstrate that at least 1 hour of direct observation occurred weekly.
Supervisor will ensure that at least 1 hour of direct service occurs for all employees requiring direct observation. This will be reported within a supervision note which will include an identifier of the client being observed. Supervision notes will be signed off by the employee and supervisor and kept on site.
Compliance will be monitored by the PD who will review all supervision notes weekly and then submitted to clinical compliance officers for additional review.
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