Observations
Based on a review of nine personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.Employee #9 was hired on December 5, 2022 as a counselor assistant as is still current in that position. Employee # 9 has a high school diploma and 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. Employee #9 did not receive documented direct supervision from December 2022- February 2023 or documented close supervision from March 2023- present. Direct observation is defined by regulation as follows: " In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities " . In accordance with 28 Pa. Code 704.9(a), a counselor assistant must be supervised by a fulltime clinical supervisor or a full-time counselor. The fully qualified clinical supervisor or counselor is then responsible for weekly supervision notes relating to the counselor assistant. Clear documentation in the weekly notes and in the pertinent client charts must also demonstrate that direct observation is occurring.Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week. "Documented supervision did not identify that direct observation or formal case reviews were occurring. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor assistants with a high school diploma or GED may counsel clients only under direct observation of a counselor or clinical supervisor for the first three months of employment. For the next nine months the counselor assistant may only counsel under the close supervision of a counselor or clinical supervisor. No later than 8/31/23, the clinical supervisor will conduct a training session, for all clinical and quality assurance staff, regarding Chapter 704 Staffing requirements for drug and alcohol treatment activities, specifically, 704.8 Qualifications for the position of counselor assistant, 704.9 Supervision of counselor assistant and 704.10 Promotion of counselor assistant. The project director will follow-up to ensure that clinical staff has received and understands this training. The quality assurance staff, through ongoing reviews of training documents, will ensure that counselor assistant training is properly documented in accordance with Chapter 704 Staffing requirements for drug and alcohol treatment activities. Employee #9 is currently enrolled in a bachelor's degree program and is 2 semesters away from receiving her degree, she will continue to work under the close supervision of the clinical supervisor. |
Observations
Based on a review of the facility ' s policy and procedure manual and client records, the facility failed to review and update treatment and rehabilitation plans biweekly, per facility policy, in six of seven records reviewed. Client #2 was admitted on January 9, 2023 and discharged on April 18, 2023. Client #2 had a treatment and rehabilitation plan dated January 9, 2023, a treatment plan update was no later than January 23, 2023; however, it was not completed until February 7, 2023. The next update was due by February 21, 2023 but was not completed until March 9, 2023. The next update was due March 23, 2023 but was not completed until April 7, 2023.Client #3 was admitted on December 28, 2022 and was discharged on May 13, 2023. Client #3 had a treatment and rehabilitation plan dated December 28, 2022, a treatment plan update was no later than January 11, 2023; however, it was not completed until January 26, 2023. The next update was due by February 9, 2023 but was not completed until February 24, 2023. The next update was due March 10, 2023 but was not completed until March 27, 2023. The next update was due April 10, 2023 but was not completed until April 26, 2023. The next update was due May 10, 2023, but no update was documented. Client #4 was admitted on November 30, 2022 and was discharged on March 27, 2023. Client #4 had a treatment and rehabilitation plan dated November 30, 2022, a treatment plan update was no later than December 14, 2022; however, it was not completed until December 29, 2022. The next update was due by January 12, 2023 but was not completed until January 27, 2023. The next update was due February 10, 2023 but was not completed until February 27, 2023. The next update was due March 13, 2023, but no update was documented. Client #5 was admitted on March 24, 2023 and was current at the time of the inspection. Client #5 had a treatment and rehabilitation plan dated March 24, 2023, a treatment plan update was no later than April 7, 2023; however, it was not completed until April 21, 2023. The next update was due May 5, 2023 but was not completed until May 22, 2023. The next update was due June 5, 2023, but no additional updates were documented.Client #6 was admitted on February 21, 2023 and was current at the time of the inspection. Client #6 had a treatment and rehabilitation plan dated February 21, 2023, a treatment plan update was no later than March 7, 2023; however, it was not completed until March 22, 2023. The next update was due April 5, 2023 but was not completed until April 21, 2023. The next update was due May 5, 2023 but was not completed until May 19, 2023. The next update was due June 2, 2023 but was not completed until June 20, 2023. Client #7 was admitted on December 1, 2022 and was current at the time of the inspection. Client #7 had a treatment and rehabilitation plan dated December 1, 2022, a treatment plan update was no later than December 15, 2022; however, it was not completed until December 30, 2022. The next update was due January 13, 2023 but was not completed until January 27, 2023. The next update was due February 10, 2023 but was not completed until February 27, 2023. The next update was due March 13, 2023 but was not completed until March 30, 2023. The next update was due April 13, 2023 but was not completed until April 28, 2023. The next update was due May 12, 2023 but was not completed until May 26, 2023. The next update was due June 9, 2023 but no update was documented. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan reviews, by regulation 709.52(b), must be completed at least every 30 days for projects whose client treatment regime is more than 30 days. This project's treatment regime is 90 days. The original treatment plan review policy in the facility's policy and procedure manual stated that treatment plan reviews shall be completed bi-weekly. This was incorrect. The policy regarding treatment plan reviews has been updated / corrected by the Project Director with agreement by the Governing Body to "treatment plan reviews will be completed at least every 30 days". These changes will be noted in the attestations, "changes to the approved written policy submitted to DDAP and a revised policy is attached" box will be checked to be reviewed with the DDAP inspection staff. All clinical staff have been notified that treatment plan reviews shall be conducted at least every 30 days. |
Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project, including follow up information in two out of four applicable records.Client #1 was admitted on May 24, 2023 and was discharged on June 8, 2023. There was no follow up information documented in the record. Client #2 was admitted on January 9, 2023 and discharged on April 18, 2023. There was no follow up information documented in the record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility policy and procedure manual, regarding client follow-up, states "Any client who successfully completes our program...will be contacted for follow-up at 30, 90, and 180 days after discharge." the policy has been changed to "All clients, regardless of type of discharge, will be contacted for a follow-up at 30, 90, and 180 days after discharge". The follow-up policy has been updated by the Project Director with agreement by the Governing Body, to include all discharges. These changes will be noted in the attestations, "changes to the approved written policy submitted to DDAP and a revised policy is attached" box will be checked to be reviewed by the DDAP inspection staff. All clinical staff have been notified during a training session on 7/6/23 that follow-ups shall be attempted for all clients regardless of type of discharge. The Clinical Supervisor will ensure that this policy is incorporated through reminders of the updated policy during weekly staff meetings and is monitored through quality assurance staff chart reviews and by ongoing, weekly reports from the quality assurance staff to the Project Director and the Clinical Supervisor. |