Observations
Based on a review of five personnel records, the facility failed to ensure proper documentation that two counselor assistants were counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #4 was hired as a counselor assistant on October 4, 2021. Employee #4 has a master ' s degree and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment. Employee #4 did not receive close supervision from October 2021 to December 2021. 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 ". During documented supervision on October 4, 5, 6, 12, 13, 14, 19,20, 21, 27, 28, and 29 2021, November 1, 2, 3, 9, 10, 11, 17, 18, 19, 22, 23, and 24, 2021 and December 1, 2, 3, 8 9. 10, 13, 14, 15, 21, 22, and 23, 2021 neither direct observation or case review were documented.
Employee #5 was hired as a counselor assistant on April 7, 2020. Employee #5 has a bachelor ' s degree and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment. Employee #5 did not receive close supervision from August 2021 - February 2022. 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 " . During documented supervision on August 23, 24 and 25, 2021; September 1, 2, 3, 7, 8,9 10, 15,16, 17, 28, 29 and 30, 2021; October 4, 5, 6, 12, 13, 14 19, 20, 21, 27, 28, and 29, 2021; November 1,2,3, 9,10,11, 17,18,19, 22, 23, and 24, 2021, December 1,2,38,9,10, 13,14,15, 21,22, and 23, 2021, January 3,4,5, 11,12,13, 19,20,21, 24, 25, and 26, 2022 and February 1, 2, 3, 8, 9, and 10, 2022 neither direct observation or case review were documented.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
This has been discussed between Administration since the inspection. Going forward the counselor assistants will receive closer supervision through documented case reviews and more specific notes contained within their employee files. In addition, all progress notes of counselor assistants will be signed by the individual conducting direct supervision. The Clinical Supervisor will be responsible for ensuring the corrective action is implemented through weekly checks. |
Observations
Based on a review of seven client records, the facility failed to provide counseling to clients on a regular and scheduled basis in three records reviewed.
Client #1 was admitted on September 14, 2021 and was still active at the time of the inspection. The comprehensive treatment plan, dated November 19, 2021, indicated three group sessions per week. The record of service and progress notes indicated that the client had received no group sessions at the time of the inspection.
Client #3 was admitted on October 12, 2021 and was still active at the time of the inspection. The comprehensive treatment plan, dated October 12, 2021, indicated three group sessions per week. The record of service and progress notes indicated that the client had received no group sessions at the time of the inspection.
Client #4 was admitted on September 29, 2021 and was still active at the time of the inspection. The comprehensive treatment plan, dated September 29, 2021, indicated three group sessions per week. The record of service and progress notes indicated that the client had received no group sessions at the time of the inspection.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
This particular counselor has been addressed in regards to this situation by the Clinical Supervisor since the inspection. She is now aware that the treatment plan needs to reflect what is actually happening treatment wise. The Clinical Supervisor and Lead Counselor will sit with the employee and re-train. The treatment plan will be re-done with the client at the next scheduled session to reflect the actual treatment taking place. It will be signed by the counselor, client and supervisor to ensure accuracy. Again, this will be addressed with every clinician during staff meetings and individual supervision. |