INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 27, 2021 through April 29, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health Systems at Williamsburg 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 the review of twenty-five personnel records, the project failed to ensure that eight of fifteen counselor assistants reviewed received direct observation and/or close supervision that is in compliance with the regulatory timeframes.Employee #11 was hired as a counselor assistant on June 15, 2020 and was a current employee at the time of the inspection. Since employee #11 has a high school diploma, the employee is to only counsel clients under the direct observation of a trained counselor or clinical supervisor for the first three months of employment and only under close supervisor for the following nine months. There was no documentation in the personnel record of direct observation from July 3, 2020 through September 15, 2020 and no documentation of close supervision from September 15, 2020 through April 15, 2021, which entails one hour of documented case review per week and one hour of documented direct observation per week. Employee #12 was hired as a counselor assistant on January 27, 2020 and was a current employee at the time of the inspection. Since employee #12 has a high school diploma, the employee is to only counsel clients under the direct observation of a trained counselor or clinical supervisor for the first three months of employment and only under close supervisor for the following nine months. There was no documentation in the personnel record of close supervision from August 7, 2021 through January 27, 2021, which entails one hour of documented case review per week and one hour of documented direct observation per week. Employee #13 was hired as a counselor assistant on September 21, 2020 and was a current employee at the time of the inspection. Since employee #13 has a high school diploma, the employee is to only counsel clients under the direct observation of a trained counselor or clinical supervisor for the first three months of employment and only under close supervisor for the following nine months. There was no documentation in the personnel record of direct observation from September 21, 2020 through December 21, 2020 and no documentation of close supervision from December 21, 2020 through April 5, 2021, which entails one hour of documented case review per week and one hour of documented direct observation per week. Employee #16 was hired as a counselor assistant on March 9, 2020 and was a current employee at the time of the inspection. Since employee #16 has a high school diploma, the employee is to only counsel clients under the direct observation of a trained counselor or clinical supervisor for the first three months of employment and only under close supervisor for the following nine months. There is no documentation in the personnel record of close supervision from June 29, 2020 through March 9, 2021, which entails one hour of documented case review per week and one hour of documented direct observation per week. Employee #17 was hired as a counselor assistant on March 25, 2020 and was a current employee at the time of the inspection. Since employee #17 was hired with a qualifying Bachelor ' s Degree, but with no previous clinical experience, the employee was to only counsel clients under the close supervision of a trained counselor or clinical supervisor for at least the first six months of employment; however, there was no documentation in the personnel record of close supervision from June 19, 2020 through September 25, 2020, which entails one hour of documented case review per week and one hour of documented direct observation per week.Employee #19 was hired as a counselor assistant on April 20, 2020 and was a current employee at the time of the inspection. Since employee #19 was hired with a qualifying Bachelor ' s Degree, but with no previous clinical experience, the employee was to only counsel clients under the close supervision of a trained counselor or clinical supervisor for at least the first six months of employment; however, there was no documentation in the personnel record of close supervision from July 3, 2020 through September 15, 2020, which entails one hour of documented case review per week and one hour of documented direct observation per week.Employee #20 was hired as a counselor assistant on June 8, 2020 and was a current employee at the time of the inspection. Since employee #20 was hired with a qualifying Bachelor ' s Degree, but with no previous clinical experience, the employee was to only counsel clients under the close supervision of a trained counselor or clinical supervisor for at least the first six months of employment; however, there was no documentation in the personnel record of close supervision from August 7, 2020 through December 8, 2020, which entails one hour of documented case review per week and one hour of documented direct observation per week.Employee #21 was hired as a counselor assistant on January 4, 2021 and was a current employee at the time of the inspection. Since employee #21 was hired with a qualifying Bachelor ' s Degree, but with no previous clinical experience, the employee was to only counsel clients under the close supervision of a trained counselor or clinical supervisor for at least the first six months of employment; however, there was no documentation in the personnel record of close supervision from February 1, 2021 through April 23, 2021, which entails one hour of documented case review per week and one hour of documented direct observation per week.These findings were reviewed with project staff during the licensing process.This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
Direct observation and close supervision requirements/regulations were reviewed with the clinical supervisors after our inspection.
The counselor/counselor assistant supervision form has been changed to add specific lines to document close supervision times and direct observation times.
Supervision forms will be handed into the CEO monthly.
The CEO will ensure completion and that direct observation and close supervisions are followed.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of twenty-five personnel records, the project failed to ensure that employee's #17 and #18 received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.Employee #17 was employed as a counselor assistant on March 25, 2020 and was to receive communicable disease trainings no later than March 25, 2021; however, there is no documentation in the personnel record verifying that the employee received the HIV/AIDS training as of the date of the inspection.Employee #18 was employed as a counselor assistant on October 7, 2019 and was to receive communicable disease trainings no later than October 7, 2020; however, documentation in the personnel record indicated that the employee did not receive the TB/STD and other health related topics training until February 26, 2021.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Update: Both employees had their communicable disease training completed late.
Employee #17 had communicable disease training completed on 4/20/21 (it was due 3/25/21).
Employee #18 had communicable disease training on 2/26/21 (it was due on 10/7/20).
The COO gets a list of new hires monthly and tracks who is in need of HIV/AIDS and TB/STD trainings. Both the employee and the supervisor will be notified when these trainings are being offered.
The CEO is making a check off sheet of required trainings/supervisions for all new counselors/counselor assistants and the clinical supervisors will use this sheet for tracking purposes.
HIV/AIDS and TB/STD trainings will be offered a minimum of two times per year and more if needed.
The COO will ensure compliance for all employees with obtaining their HIV/AIDS and TB/STD trainings according to regulation. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in three of twenty-one records reviewed.Client #8 was admitted on April 19, 2021 and was a current client at the time of the inspection. A release of information form to a clergy member, signed and dated by the client on April 19, 2021, did not document the specific information to be disclosed.Client #10 was admitted on February 3, 2021 and was a current client at the time of the inspection. A release of information form to a paramour, signed and dated by the client on February 19, 2021, did not document the specific information to be disclosed.Client #11 was admitted on October 13, 2020 and was discharged on November 3, 2020. A release of information form to a family member, signed and dated by the client on October 15, 2020, did not document the specific information to be disclosed.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Update:
Client #10 is still in treatment and the consent for his paramour is being corrected today.
Client #8 is no longer in treatment.
Managers who have staff who complete the releases of information will re-educate their staff on the importance of full completion of the release as well as how to properly complete a release of information.
In addition, the medical records director will send out an email to all staff reminding individuals of the importance of full completion of a consent.
Medical records staff will review the releases of all new admits for the next 3 months to ensure proper completion.
The Director of medical records will ensure compliance and proper completion of consents. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on the review of client records, the project failed to ensure that clients in the partial hospitalization program receive individual counseling at least twice weekly in six of seven applicable client records reviewed.Client #15 was admitted on March 10, 2021 and was a current client at the time of the inspection. There is no documentation in the client record that the client received the two individual counseling sessions required for the week of March 14, 2021 through March 20, 2021 and one of the two individual counseling sessions required for the weeks of April 4, 2021 through April 10, 2021 and April 11, 2021 through April 17, 2021.Client #16 was admitted on March 6, 2021 and was a current client at the time of the inspection. There is no documentation in the client record that the client received the two individual counseling sessions required for the weeks of March 21, 2020 through March 27, 2021, April 4, 2021 through April 17, 2021 and April 18, 2021 through April 24, 2021.Client #17 was admitted on March 4, 2021 and was a current client at the time of the inspection. There is no documentation in the client record that the client received the two individual counseling sessions required for the weeks of March 7, 2021 through March 13, 2021, March 14, 2021 through March 20, 2021, April 11, 2021 through April 17, 2021 and April 18, 2021 through April 24, 2021. Additionally, there is no documentation in the client records that the client received one of the two individual counseling sessions required for the weeks of March 21, 2021 through March 27, 2021, March 28, 2021 through April 3, 2021 and April 4, 2021 through April 10, 2021.Client #19 was admitted on October 30, 2020 and was discharged on November 25, 2021. There is no documentation in the client records that the client received one of the two individual counseling sessions required for the weeks of November 8, 2020 through November 14, 2020 and November 15 through November 21, 2020.Client #20 was admitted on November 25, 2020 and was discharged on December 21, 2020. There is no documentation in the client record that the client received the two individual counseling sessions required for the week of December 12. 2020 through December 18, 2020.Client #21 was admitted on February 3, 2021 and was discharged on April 8, 2021. There is no documentation in the client record that the client received the two individual counseling sessions required for the weeks of February 13, 2021 through February 19, 2020, February 20, 2021 through February 26, 2021, March 6, 2021 through March 12, 2021 and March 27, 2021 through April 2, 2021. Additionally, there is no documentation in the client records that the client received one of the two individual counseling sessions required for the weeks of March 13, 2021 through March 19, 2021 and March 21, 2021 through March 26, 2021.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The partial hospital program (PHP) clinical supervisor will re-educate the (PHP) counselors on the importance of making sure there are two individual notes per week in all PHP client records.
PHP counselors will alert the clinical supervisor if they are having difficulty completing two individual sessions per week so the clinical supervisor can make arrangements for two individuals to be completed.
The PHP clinical supervisor will audit 20 charts for the next 4 months to ensure two individual sessions per week are occurring. The PHP clinical supervisor will ensure compliance. |
709.83(a)(10) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(10) Discharge summary.
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Observations
Based on the review of client records, the project failed to document a complete client record that included a discharge summary in three of seven applicable client records reviewed.Client #19 was admitted on October 30, 2020 and was discharged on November 25, 2021. A discharge summary was not documented in the client ' s record.Client #20 was admitted on November 25, 2020 and was discharged on December 21, 2020. A discharge summary was not documented in the client ' s record.Client #21 was admitted on February 3, 2021 and was discharged on April 8, 2021. A discharge summary was not documented in the client ' s record.These findings were reviewed with project staff during the licensing process.This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
The clinical supervisors will aid/assign a designee(s) to help get deficient discharge summaries caught up.
The clinical supervisors will re-educate the clinical staff on the importance of completing the discharge summary within 7 days of discharge.
If a clinical team member is unable to complete the discharge summary within 7 days, he/she will notify his/her clinical supervisor so arrangements can be made for timely completion.
Each clinical supervisor will monitor 15 charts for the next 4 months to ensure discharge summaries are completed within 7 days after discharge. These audits will be turned into the COO. Clinical supervisors will ensure compliance. |