INITIAL COMMENTS
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This report is a result of a licensure renewal inspection. The physical plant inspection was conducted on December 29, 2022, and the client records review inspection was 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, Pennsylvania Counseling Services Lancaster City 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 fourteen 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 #14 was hired on June 16, 2022 as a counselor assistant. Employee #14 has a bachelor's degree and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for the first 6 months of employment. 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 only clinical skill development and direct observation occurred however formal case reviews did not occur. Employee #14 did not receive close supervision from June 16, 2022 to January 16, 2023.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Quality Improvement has revised the weekly close supervision documentation to include direct observation information, a case review, and development of clinical skills. The Director of Quality Improvement provided education to the Counselor Assistant Supervisors on 3/10/23 and 3/13/23, reviewing the regulatory requirements for documenting the close supervision process to ensure that all future documentation contains each of the required pieces. The Director of Quality Improvement will monitor the content of the revised close supervision notes to promote ongoing compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven records reviewed.
Client #1 was admitted on August 29, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on September 21, 2022, and the next update was due no later than November 21, 2022; however, the next update was completed on November 26, 2021. The next update was due no later than January 26, 2023; however, it was not completed until February 7, 2023.
Client #6 was admitted on March 16, 2022 and discharged on November 11, 2022. A treatment plan update was completed on July 28, 2022, and the next update was due no later than September 28, 2022; however, it was not completed until October 4, 2022.
Client #7 was admitted on July 11, 2022 and discharged on November 4, 2022. A comprehensive treatment plan was completed on August 9, 2022, and the next update was due no later than October 9, 2022; however, it was not completed until October 18, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Implementation for Outpatient Services provided re-education to all clinical staff regarding treatment plan timeframes during a staff meeting held on 3/23/23. The facility's Office Administrator will be responsible for ongoing compliance and will track the completion of treatment plan updates for all clients. The Office Administrator will oversee that clinical staff are re-educated as needed to review and update treatment plans at least every 60 days. |