INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 31,2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Colonial House Outpatient was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 direct observation supervision for a counselor assistant with a high school diploma for the first 3 months of employment.
The findings include:
Employee #5 was hired as counselor assistant with a high school diploma, but the facility failed to provide documentation of direct observation supervision for the first three months of employment.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee #5 was hired on 10/3/2016 as a counselor assistant with a high school diploma. There is documentation of employee #5 completing his close supervision period as well as being assessed as capable of carrying a full caseload in a performance evaluation for the period of 10/3/2017-4/3/2018 however; the record continues to lack any documentation associated with direct supervision within the first 3 months of employment.
The clinical supervisor who was responsible for this documentation is no longer with the agency. The newly hired clinical supervision (6/1/2018) has been trained by the Executive Director on the proper documentation of supervision for counselor assistants.
Employee #5 will be directly supervised from 7/1/2018-10/1/2018. This direct supervision will consist of the clinical supervisor observing clinical activities such as assessment, groups, and individual sessions. This supervision will be documented on weekly supervision notes which will be submitted to the Facility Director for review. The supervision notes will be added to employee #5 personnel file. Employee #5 will be provided with written notice of the completion of the direct supervision period by the clinical supervisor. This documentation will also be submitted to the facility director for review and inclusion in personnel file.
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709.93(a)(3) LICENSURE Client records
709.93. 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:
(3) Record of services provided.
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Observations
The facility failed to document a complete client record in 4 out of 7 records.
The findings include:
Client #1 was admitted 2/26/18 and was still an active client at the time of inspection. Progress notes dated 5/14/18, 5/21/18 and 5/29/18 were not included on the record of service.
Client #3 was admitted 2/5/18 and was still an active client at the time of inspection. A progress note dated 5/18/18 was not included on the record of service.
Client #4 was admitted 3/27/18 and was still an active client at the time of inspection. Progress notes dated 5/17/18 and 5/22/18 were not included on the record of service
Client #5 was admitted 2/21/18 and was still an active client at the time of inspection. Two progress notes dated 5/22/18 were not included on the record of service
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During staff meeting on 6/7/2018, clinical supervisor re-trained all staff on the proper completion of the client contact log (record of services); specifically making sure that all group and individual notes are logged in order and entries are legible. Compliance will be maintained by the clinical supervisor through regular chart audits and supervision. |