This report is a result of a licensure renewal inspection. The physical plant inspection was conducted on January 30, 2023, and the client records review inspection was conducted on February 15, 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 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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Observations
Based on a review of six personnel records, the facility failed to ensure that two counselor assistants were counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee # 5 was hired on May 5, 2022 as a counselor assistant. Employee #5 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. " Employee #5 did not receive close supervision from May 5, 2022 to January 25, 2023. During documented supervision only clinical skill development and direct observation occurred; however, formal case reviews did not occur.
Employee # 6 was hired August 11, 2022 as a counselor assistant. Employee #6 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. " Employee #6 did not receive close supervision from August 11, 2022 to January 16, 2023. During documented supervision only clinical skill development and direct observation occurred; however, formal case reviews did not occur.
These findings were 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. |