INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago Snyder, 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 and a plan of correction is due on April 19, 2011.
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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 employee personnel record, the facility failed to document the required period of direct observation supervision for one counselor assistant represented by personnel record #5.
The findings include:
Five personnel records were reviewed on March 25, 2011. One of the five personnel records reviewed was for the position of counselor assistant. The counselor assistant represented in personnel record # 5, did not have documentation of direct observation in the personnel record. Employee record # 5 contained documentation of an Associate's Degree in Business-Accounting. The degree is not a qualifying degree. Per regulation, a counselor assistant with a high school diploma or GED equivalent may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first three months of employment. Employee #5 is required to have three months of direct observation followed by nine months of close supervision.
The lack of documentation for the direct observation period was confirmed by the facility director on March 25, 2011.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.12(b) & (c) & (d) LICENSURE Counselor Asst/Exceptions
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(b) Counselor assistants. Counselor assistants may be included in determining FTE ratios when the counselor assistant is eligible for a caseload.
(c) Exemption for transitional living. Specific client/staff ratios are not required for transitional living facilities.
(d) Exceptions. A project director may submit to the Department a written petition requesting an exception to the client/staff and client/counselor ratios in this section. The petition shall describe how the characteristics of the program and its client mix support the request for the exception and shall be approved by the governing body. Granting the petition shall be at the discretion of the Department. Long-term residential facilities and halfway houses which include a client's participation in schooling or employment as part of a treatment day are examples when requests for exceptions will be considered.
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Observations
Based on a review of the staffing requirements facility summary report form completed by the facility director and a discussion with the facility director on March 25, 2011, the counselor assistant, represented by personnel record #5, was assigned a caseload but was not eligible for a caseload.
The findings included:
On March 25, 2011 two counselor outpatient caseloads were reviewed and one counselor assistant outpatient caseloads were reviewed. Per regulation, a counselor assistant may be included in determining FTE ratios when the counselor assistant is eligible for a caseload.
The counselor assistant, represented by personnel record #5 was hired on January 31, 2011. Based on the counselor assistant's qualifying degree, the counselor assistant would not be eligible for a caseload until the direct observation period has been completed and a positive assessment of the counselor's individual skill level has been completed. The counselor assistant was still under direct observation and therefore not eligible to be counted in the FTE ratio.
This was discussed with the facility director on March 25, 2011. The facility director confirmed that the counselor assistant was not yet eligible for a caseload.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |