INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 16, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Wyoming Valley Alcohol and Drug Services, Inc. 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
Based on a review of personnel records, the facility failed to ensure that all counselor assistants, with a high school diploma or General Education Development (GED), were counseling clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment and under the close supervision of a trained counselor or clinical supervisor for the next 9 months of employment.
Employee # 6 was hired as a high school diploma/GED level counselor assistant on October 14, 2021. The supervision notes did not indicate that close supervision, defined as formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week, was occurring once a week during the month of March 2022.
This is a repeat citation from the February 15, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have met as an supervisory team to discuss this issue. Even though 6 months of supervision was completed, we do realize that we were missing elements such as formal case review and an additional hour of direct observation documented per week. This will be done with the lead or clinical supervisor and assistant weekly and documented in employee files. In order to avoid happening again, as mentioned above, this will include chart reviews, consultations, direct supervision etc. We have begun the process to correct it. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that a counselor assistant satisfactorily completed the required educational and experiential qualifications prior to being promoted to the position of counselor in two of two applicable personnel records reviewed.
Employee # 5 was hired as a bachelor's-level counselor assistant on August 23, 2021 and was promoted to a counselor on February 24, 2022. At the time of the promotion, the employee only had six months of documented clinical experience in a health and human service agency; however, one year of clinical experience is required to qualify as a counselor.
Employee # 6 was hired as a high school diploma/GED-level counselor assistant on October 14, 2021 and was promoted to a counselor on April 4, 2022. At the time of the promotion, the employee did not have a qualifying degree or certification for the position of counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This will be corrected by the supervisory team by keeping those employees without both requirements as Counselor Assistants for at least one year. This includes weekly supervision with all the elements required as per meeting and documentation. After 1 year, they will be evaluated and promotion will occur if all requirements have been satisfied. As far as employees 5, they will need to continue as an assistant until experience is met, supervisory time is positive, and evaluation allows for promotion to counselor. This will conducted by the Clinical Supervisor and lead counselor to ensure supervision and experience is met to be a Counselor. Employee 5 was changed back to assistant effective 2-17-23. Employee #6 actually put their resignation in and will remain assistant until last day in 2 weeks. In the #6 instance, we will only hire individuals with a qualifying degree moving forward. |