INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Insights, Inc. was found not to be 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
Based on a review of the employee personnel record, the facility failed to document the required period of direct observation supervision and close supervision for two counselor assistants.
The findings include:
Eighth personnel records were reviewed on March 10, 2014. Two of the eight personnel records reviewed were for the position of counselor assistant. The counselor assistants represented in records # 3 and 4 did not have documentation of direct observation and the close supervision only documented the topic of discussion but did not include the discussion. The employees were required to have three months of direct observation and nine months of close supervision.
The clinical supervisor confirmed the lack of documentation for direct observation and close supervision on March 10, 2014.
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Plan of Correction
The Clinical Coordinator will arrange for conducting direct observation of the two counselor assistants for the next three months followed by 9 months of close supervision immediately. The weekly supervision sessions will demonstrate that at least one hour per week of direct observation is being conducted. Appropriate documentation will be completed with detail of the discussions that take place as well as the feedback that is given to the counselor assistants during the direct observation. When a counslor assistant is hired and qualifications require close observation the execuitive director who does the hiring will clearly indicate to the clinical coordinator the requirments for the new counselor assistant and the supervision activity will be confirmed by the execuitive director that the process is happening within 2 weeks of the counslor assistant starting. |