INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 20, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Conewago Place 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of five personnel records, the facility failed to provide documentation that one clinical supervisor participated in monthly meetings with their supervisor to discuss duties and performances for the first 6 months of employment in that position.
Employee# 3 was hired as a clinical supervisor on April 11, 2023 and was still in that position at the time of the inspection. There was no documentation that supervision occurred in the months of May or June 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to meet the standard of regulation 704.6, the Clinical Supervisor will participate in monthly meetings with the Corporate Clinical Director to discuss their duties and performance. These meetings occur on the second Tuesday of every month. The monthly meetings will be documented and signed on a monthly basis through the entirety of employment as Clinical Supervisor. The Facility Director will review each monthly supervision and will file documentation in the Clinical Supervisor's personnel record. In between monthly meetings, Clinical Supervisor may reach out to Corporate Clinical Director for consultations as needed. |
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 five personnel record, 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 #5 was hired on August 15, 2022 as a counselor assistant and was still employed at the time of the inspection. Employee #5 has a qualifying bachelor ' s degree but does not have the required one year of clinical experience. Employee #5 did not have the required six months of close supervision documented in the personnel record. 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 ".
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor received DDAP regulations regarding the counselor assistant requirements on 07/14/2023. These regulations were then reviewed in the Clinical Supervisor's monthly supervision with Corporate Clinical Director to clarify expectations and requirements for the supervision of counselor assistants. Staff who are identified as counselor assistants will be supervised weekly by a full-time supervisor or counselor for the required length of time based on the counselor assistant's degree. A counselor assistant with a Master's degree will receive 3 months of weekly close supervision, a counselor assistant with a Bachelor's degree will receive 6 months of weekly close supervision, and a counselor assistant with an Associate's degree will receive 9 months of weekly close supervision. Close supervision will align with DDAP regulations regarding weekly direct observation and weekly case review. Supervision notes will document a weekly case review which includes client initials or identifying number and an hour of direct observation. The hour of direct observation will then be referenced in the chart of the client with whom it is conducted. The Clinical Supervisor completing the clinical supervision sheet will observe and document the counselor assistant's interaction and intervention with the client(s), noting counselor performance and effectiveness, utilizing stated criteria specified on supervision sheets. The Clinical Supervision Sheet has been updated to present these requirements with more clarity. Supervision sessions will review the counselor assistant's clinical skills, strengths, and areas for improvement. Counselor assistants currently employed will start following this protocol immediately. The Clinical Supervisor will forward counselor assistant supervision sheets, fully completed with signatures, to the Corporate Clinical Director and the Facility Director by end of business day each Friday to ensure compliance with these regulations. The Corporate Clinical Director will review the supervision sheets to ensure compliance with the regulations and to ensure that supervision is happening as appropriate. The Corporate Clinical Director, Facility Director, and Clinical Supervisor will meet between 10/23/2023 and 10/27/2023 to determine if these will continue to be received on a weekly basis, or if the supervision sheets can be received once monthly moving forward. Signed supervision sheets for counselors will be submitted to the Corporate Clinical Director and Facility Director by the last Friday of the month. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling rooms identified as Hinkey Hall, Serenity Hall and both large groups rooms located in the west wing.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Conewago Place was granted an exception on 08/02/2023 for regulation 705.4 (3). Session privacy will be maintained by ensuring that the counseling sessions cannot be seen or heard outside the counseling areas except-by the Facility Director through password protected camera feed. Conewago Place will utilize client consent forms and record only those clients who are willing to sign the consent form. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all client bathrooms were supplied with paper towels or a mechanical dryer. Each client bathroom was provided with a towel to wash and dry hands.
This is a repeat citation from the July 28, 2022 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Conewago Place was granted an exception on 07/27/2023 for regulation 705.6 (2). In order to meet the standard of regulation 705.6 (2), the facility provides individual cloth towels during admission. Each client receives a bath towel and two wash cloths. Clients are instructed to use these cloth towels while utilizing their individual bathroom. Each client will be provided a shower caddy in which to keep their personal cloth items. The facility keeps an ample supply of bath towels and wash cloths on hand. A client may request a replacement and/or additional cloth towels when needed. The facility also has laundry onsite which clients can utilize to keep their cloth items clean. The granting of this exception will not affect any publicly accessible bathroom. Publicly accessible bathrooms will continue to be supplied with dispensers and paper towels. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. There were two fire extinguishers located in the kitchen that did not have any tags or documentation that they were inspected and approved annually.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to meet the standard of regulation 705.10, Conewago Place had 2 fire extinguishers that were located in the kitchen area inspected and approved for the year by the local fire department. The date of the inspection, 08/02/2023, is indicated on the extinguishers via inspection tag. The inspection tag is also signed off on by the Facility Director each month. |