INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the March 4, 2011 licensure renewal inspection. The follow-up inspection was conducted on August 30 , 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Carbon Monroe Pike Drug and Alcohol Commission, Inc. 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 the counselor assistant supervision logs maintained by the clinical supervisor, the facility failed to document the one hour of direct observation per week that is part of close supervision in one of one counselor assistant's supervision documentation.
The findings included:
Clinical supervision notes for a Bachelor's level counselor assistant who needed to receive six months of close supervision, which consists in part of one hour a week of direct observation, were reviewed. Supervisory notes were documented weekly from 6/27/11 to the present as required but did not include evidence of one hour a week of direct observation.
The clinical supervisor was not available on site on August 30, 2011 to provide access to the supervision notes. The notes were faxed to the Division field office on 9/1/11 and a telephone interview with the clinical supervisor on that date verified that no direct observation had occurred.
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Plan of Correction
Supervision of a Counselor Assistant: The Outpatient Supervisor will continue to meet weekly and do supervision with the Counselor Assistant documenting notes of the discussion. In addition the Outpatient Supervisor will put a weekly appointment in her groupwise calendar and sit in on at least one session a week with the counselor assistant and client for direct supervision. If the client cancels another individual session will be directly observed by the Outpatient Supervisor or a group session will be substituted for weekly supervision. The Outpatient Supervisor will discuss issues occurring during these observed sessions in weekly supervision and document any issues in the supervisor notes. This process will occur through February 2012 to ensure there is six months completed of close supervision. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document complete psychosocial evaluations in four of five client records reviewed.
The findings include:
Five client records were reviewed during the unannounced plan of correction follow up inspection of August 30 , 2011. The psychosocial evaluations were not evaluative overall and were incomplete in four of five client records reviewed.
Record # 1- The client was admitted on 6/9/11 and last treated on 8/18/11. The psychosocial evaluation was completed on 6/14/11. The evaluation failed to include documentation of the counselor's evaluation regarding the client's support systems. The document was not evaluative overall.
Record # 2- The client was admitted 7/19/2011 and last treated on 8/25/11. The psychosocial evaluation was incomplete and failed to include documentation of the client's coping mechanisms. The document was not evaluative overall.
Record # 4- The client was admitted on 6/30/11 and last treated on 8/25/11. The psychosocial evaluation was incomplete and failed to include documentation of client strengths or coping mechanisms.
Record # 5- The client was admitted on 6/6/11 and last treated on 8/22/11. The psychosocial evaluation was incomplete and failed to include documentation of client's coping mechanisms. The document was not evaluative overall.
The findings were reviewed with the clinical supervisor and were not disputed.
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Plan of Correction
Intake and Admission: This has been a recurring issue in which staff has been addressed on since previous licensing visit. Although prompts are provided and training session did occur there has been a continued problem in this area, but since this area was last noted as an issue a new Outpatient Supervisor has been hired. The Outpatient Supervisor reviewed with staff in Morning Meeting on 9/13/11 the findings in this area. Outpatient Supervisor will now check all charts after the assessment is complete and circle in pencil any deficient areas. The counselors will fix any deficiencies at the next scheduled appointment with the client. The counselors will make hand written corrections and date and initial those corrections. The Outpatient Supervisor then reviews the counselor's schedules for the week to see which clients came in and re-checks the psychosocial evaluation for completeness. If the psychosocial components continue to not be evaluative and/or complete the Outpatient Supervisor during individual supervision with a counselor will provide additional training and examples on how to complete the psychosocial. The level of individual supervision will vary depending on an individual's needs. In reference to psychosocial evaluations failing to document a client's strengths and coping skills, the Outpatient Supervisor will review examples with the whole staff at the Treatment Meeting on 9/15/11 and document in the notes for that meeting information provided to the staff. The staff will be sent by email a copy of the notes for this meeting. The Outpatient Supervisor will answer any questions from the staff during this meeting and provide individual supervision if needed to improve the quality of this section of the psychosocial evaluation. |