D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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PEACE AND HARMONY HOUSE
1150 BERKSHIRE BOULEVARD, SUITE 210
WYOMISSING, PA 19610

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Survey conducted on 10/05/2022

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on October 5, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Peace and Harmony House 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:	Plan of Correction
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.
Observations Based on a review of five personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education. Employee #5 was hired as a counselor assistant on March 28, 2022. Employee #5 has an Associate degree and may only counsel clients under the close supervision of a trained counselor or clinical supervisor for the first nine months from date of hire until December 28, 2022. Employee #5 did not receive close supervision from date of hire until the time of the inspection. The finding was reviewed with facility staff during the licensing inspection.	Plan of Correction Effective Immediately the Project Director and/or Clinical Supervisor will review the upcoming weeks appointments with the counselor assistant on Friday to decide what group and individual sessions the direct supervision will take place in. The Project Director and/or clinical supervisor will have a schedule of the direct supervision to take place that week by the end of the day Friday for all parties. All the direct supervision of at least one hour but could be more depending on the need will be documented and signed by all parties. Project Director will make sure the direct supervision of the counselor assistant is completed and documented and put in the counselor assistant personnel file. To Prevent this in the future all steps will be implemented and followed moving forward.
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.
Observations Based on a review of client records, the facility failed to ensure that the clients received individual counseling services at least two times per week in four out of five applicable records reviewed.Client #1 was admitted on July 14, 2022 and was still active at the time of the inspection. On the weeks of September 19-23, 26-30, and October 3-7, 2022 there was only one individual session documented. Client #3 was admitted on March 7, 2022 and was discharged on April 22, 2022. On the weeks of April 4-8, 11-15, and 18-22, 2022 there was no documentation of any individual sessions. Client #4 was admitted on February 28, 2022 and was discharged on April 3, 2022. On the weeks of March 7-11, 14-18, 21-25, and March 28-April 1, 2022 there was no documentation of any individual sessions. Client #5 was admitted on September 12, 2022 and was discharged on October 4, 2022. On the weeks of September 12-16, 19-23, and 26-30, 2022 there was only one individual session documented. The findings were reviewed with facility staff during the licensing inspection.	Plan of Correction Effective Immediately, Peace and Harmony House Clinical Supervisor and Administrative Assistants will make sure all PHP clients will be scheduled for two individual sessions a week, plus 15 hours of group therapy a week. Peace and Harmony House PHP Counselor will make sure that all individual and group notes are written and filed in the chart by the end of the day of being seen. If the client does not show for their individual session or group, it will be documented in a progress note and placed in the chart. Peace and Harmony House Clinical Supervisor will be auditing all PHP charts weekly for compliance to continue to make sure these steps are followed and Peace and Harmony House is in compliance with the PHP Program.