INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 10-11, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pathway to Recovery Counseling and Educational Services 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
Three personnel records were reviewed for the counselor assistant position on January 10, 2018. The facility failed to fully document the required close supervion and direct observation for employee records # 2, 4, and 8.
Employee # 2 was hired as a Bachelor's level counselor assistant on 12/6/16, and was then promoted to the counselor position on 6/6/17. The employee required close supervision for the first 6 months, which was to include at least 1 hour of direct observation per week. Weekly supervision notes were reviewed for the period of 12/15/16 - 6/6/17. Supervision notes were not documented for the following weeks:
-Week of 4/2/17
-Week of 4/9/17
-Week of 4/23/17
-Week of 5/7/17
-Week of 5/14/17
-Week of 5/21/17
-Week of 5/28/17
In addition, the facility failed to demonstrate that weekly close supervision included at least 1 hour of direct observation once a week.
Employee # 4 was hired as a Bachelor's level counselor assistant on 5/30/17 and was promoted to the counselor position on 12/5/17. The employee required close supervision for the first 6 months, which was to include at least 1 hour of direct observation per week. Weekly supervision notes were reviewed for the period of 5/30/17 - 12/5/17. Supervision notes were not documented for the following weeks:
-Week of 8/27/17
-Week of 9/3/17
-Week of 9/10/17
In addition, the facility failed to demonstrate that weekly close supervision included at least 1 hour of direct observation once a week.
Employee # 8 was hired as a Bachelor's level counselor assistant on 10/8/17. The employee requires close supervision for the first 6 months, which is to include at least 1 hour of direct observation per week. Weekly supervision notes were reviewed for the period of 10/9/17 - 12/27/17. The facility failed to demonstrate that weekly close supervision included at least 1 hour of direct observation once a week.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This citation was discussed with the members of the Quality Assurance Committee on January 19, 2018. A decision was made that all future supervision for Counselor Assistants will be monitored by the Quality Assurance Committee to make certain that supervision is scheduled weekly and that the required supervision will include at least one hour of direct observation by the clinical supervisor. All documentation will be monitored on a monthly basis by the Clinical Case Manager to make certain that each observation and supervision session is documented appropriately. The President and CEO will be responsible for implementing and monitoring this procedure. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Eight personnel records were reviewed for the licensing renewal inspection on January 10, 2018. The facility failed to document the provision of required HIV/AIDS and/or STD/TB training for employee records # 2 and 6.
Employee # 2 was hired by the facility on 12/6/16 as a counselor assistant, and then began employment in the counselor position on 6/6/17. HIV/AIDS training was due to be completed by no later than 12/6/17. Documentation of this training was not found in the employee's record.
Employee # 6 was hired by the facility on 5/20/16 as a counselor. All required hours for HIV/AIDS training and STD/TB training were due to be completed by no later than 5/20/17. The employee's record contained documentation of HIV/AIDS and STD/TB training, completed prior to hire at the facility. However, the facility was unable to confirm that the employee received at least 6 hours of HIV/AIDS training and at least 4 hours of STD/TB training.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Both Employee #2 and Employee #6 have been scheduled and will be completing the required 6 hour HIV Training on 2/27/2018. In the future in an effort to ensure this deficiency does not occur again, the Fiscal Manager, who is responsible for maintaining the Training Manual for all staff members, will set up a mandatory training schedule for all new staff. She will check the online DDAP training site weekly for available mandatory trainings. The Fiscal Manager will then schedule the trainings for new staff making certain that all staff complete mandatory trainings within the first year of employment. This procedure was implemented and will be monitored by the President and CEO. |
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
Eight personnel records were reviewed for the licensing renewal inspection on January 10, 2018. The facility failed to document the provision of instruction in the use of fire extinguishers upon staff employment for employee record # 7.
Employee # 7 was hired by the facility on 5/1/17 as a counselor. Documentation of fire extinguisher instruction was not found in the employee's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee #7 was instructed by the President & CEO on the proper use of a fire extinguisher on 1/15/2018. Documentation of the fire extinguisher instruction was placed in her personnel file. In the future, the department supervisor will be responsible for providing the instruction of the proper use of a fire extinguisher, as well as other safety protocol, for his/her new staff. The department supervisor will be responsible for placing the documentation of the fire extinguisher instruction in the staff's personnel file. The Fiscal Manager, who maintains all personnel files, will be responsible for making certain that this procedure is completed for all new staff. |
709.28 (c) 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.
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Observations
Fifteen client records were reviewed for the licensing renewal inspection on January 10-11, 2017. The facility failed to obtain an informed and voluntary consent to release information for client record # 8.
Client # 8 was admitted into treatment on 8/30/17 and was still active in treatment. Documentation in the client's record indicated that the facility faxed a letter to a state
agency on 12/26/17, reporting the client's presence in treatment and substance abuse diagnosis. A consent to release information to this state agency was not documented in the client's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Release and Consent Form for information disclosed to outside services/individuals was discussed in great detail during the Treatment Team Meeting on January 15, 2018. It was stressed, during this meeting, that the agency's Release and Consent Form must be completed for each and every person/agency wishing to obtain information about a current or former client of the agency. Furthermore, all clinicians will be required to check the client's record for the proper Release and Consent Form prior to submitting the correspondence. This policy will be monitored for adherence and compliance by the Clinical Case Manager who will review all clinical charts on a monthly basis to ensure that there are Release and Consent Forms signed for all correspondence. |