INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 12, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Way of Life 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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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of staffing records, the facility failed to provide documentation that a counselor assistant was working towards counselor status. Staff #4 was hired on December 1, 2021 and still employed at the time of the inspection. There was no documentation for the prior calendar year that staff #4 was actively working towards counselor status. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/25/2023 the director and clinical supervisor met with staff #4, counselor assistant, and reviewed the requirement for the annual documentation for how the counselor assistant is actively working towards counselor status. To ensure compliance staff #4, counselor assistant, will be notified by the clinical supervisor quarterly during supervision of the requirement to be documenting how they are actively working towards counselor status for the year. For all current and future counselor assistants documentation will be completed each year the person is in the counselor assistant role position and will be reviewed by the clinical supervisor to ensure compliance. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project in two of two applicable records. Client #4 was admitted April 18, 2023 and discharged on June 12, 2023. There was no documentation that client #4 was provided written notification of the involuntary termination.Client #6 was admitted January 9, 2023 and discharged on February 24, 2023. There was no documentation that client #4 was provided written notification of the involuntary termination.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/26/2023 during clinical meeting the clinical staff was retrained regarding notifying each client in writing if they are going to be involuntarily discharged from the program. The clinical staff was trained on what needed to documented in the notification and that it needed to be presented to the client prior to the client being involuntarily discharged from the program. To ensure compliance discharge files will be audited on a monthly basis by the clinical supervisor to ensure documentation of notification was made available to any client that was involuntarily discharged from the program. |