INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 10-11, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Western Pennsylvania Teen Challenge 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
The facility failed to document close supervision for a Bachelor's level counselor for the first 6 months of employment.
One counselor assistant was reviewed on April 10-11, 2018. Staff #4 was hired as a counselor assistant on February 28, 2018. Close supervision was not documented for staff #4.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Lead counselor will supervise all counselor assistants and counselors. This supervision will be done by supervising and providing feedback on individual and group counseling sessions and by meeting weekly with the counselor assistant(s) and/or counselor(s). The weekly reviews will be documented. Also, a list of topics that will be discussed between lead counselor and counselor assistant(s) and/or counselor(s) will be recorded and placed in an HR File. At the end of the supervisory period, a summary of counselor assistant's progress will be written and placed in an HR File. Retrospectively, the lack of supervisory documentation for staff #4 has already been fixed. Prospectively, lead counselor will make sure this lack of documentation does not occur again in the future by: 1. making documentation a reoccurring item on weekly senior leadership team meeting agenda. 2. making a personal weekly reoccurring reminder on digital calendar. 3. set specific dates and times with counselors and/or counselor assistants for the weekly review meeting and make reminder on our mutual digital calendar. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facilty failed to document the type and frequency of services on the treatment plan.
Seven client records were reviewed on April 10-11, 2018. Client records #1, 2, 3, 4, 5, 6 and 7 did not include documentation of the type and frequency of all services on the treatment plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Lead counselor will ensure that type and frequency of treatment plan services/interventions are timely and accurately documented. Lead counselor will audit counseling files to ensure this documentation is occurring and he will regularly discuss treatment plans with all counselors during clinical team meetings. |
709.53(a) LICENSURE Complete Client Record
709.53. 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:
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Observations
The facility failed to document a complete client record which included case consultations, aftercare plans and follow up.
Seven client records were reviewed on April 10-11, 2018. Client records #4, 5, 6 and 7 did not include documentation of a case consultation, aftercare plan and/or follow up.
Client #4 was admitted on 8/24/17 and discharged on 9/23/17. Client record #4 did not include documentation of a follow up.
Client #5 was admitted on 6/7/17 and discharged on 7/6/17. Client record #5 did not include documentation of a case consultation, aftercare plan and follow up.
Client #6 was admitted on 10/10/17 and discharged on 11/7/17. Client record #6 did not include documentation of a case consultation, aftercare plan and follow up.
Client #7 was admitted on 11/8/17 and discharged on 12/4/17. Client record #7 did not include documentation of a case consultation and follow up.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Lead counselor will ensure that case consults, aftercare plans, and follow up procedures are 1. Occurring and 2. Documented. Lead counselor will audit all counselors files to ensure these procedures are occurring and being documented. Also, lead counselor will discuss these 3 procedures and send reminder emails about these 3 procedures regularly with all counselors. Lead counselor will create a checklist for all counselors to check and sign that indicates these 3 procedures are occurring. |