INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on September 6, 2023 from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Ascend Clinical Services 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 personnel records and supervision notes, the facility failed to document the required supervision for two of two staff.
Staff #1 was hired as a counselor on April 11, 2022. At the time of hire, staff #1 met the bachelor's level educational requirements for the position of counselor; however, he did not have the required one year of clinical experience. An annual licensing inspection was conducted on February 14, 2023, at which time the facility was cited for staff #1 not meeting counselor qualifications. A plan of correction was submitted and approved on March 3, 2023 stating that staff #1 would be provided with six months of close supervision. There was three and a half months of supervision documented for staff #1 starting on March 31, 2023 and ending on July 13, 2023.
Staff #2 was hired as a counselor assistant on March 29, 2023. At the time of hire, staff #2 met the bachelor's level educational requirement for counselor assistant and required documentation of close supervision. There were no supervision notes documented for staff #2.
These findings were reviewed with facility staff.
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Plan of Correction
Starting on 10/05/2023 Ascend clinical services will provide documented close supervision to all counselor assistants and counselors who do not meet the requirement as full counselor. This includes weekly direct supervision. Ascend clinical services will provide weekly supervision to all counselors. This will be completed by the clinical supervisor. ON top of this Ascend Clinical Services will hire two new full time qualified counselors who will begin providing counseling services on 10/16/2023 and 10/23/2023.
The two counselors that were identified during this site visit no longer work at Ascend Clinical Services and two new full counselors were hired to fill the position. Both of the new counselors have their masters degree with multiple years of experience in the drug and alcohol field. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff schedules and administrative documentation, the facility failed to document that at least one person trained in CPR and First Aid was onsite during the project's hours of operation.
The staff schedules were reviewed for July and August 2023. The overnight shift, 11:00 PM - 7:00 AM, is covered by one support staff person. The overnight staff coverage for July 1, 7, 15, 21, 22, 28, 29 and August 5, 12, 18 and 26, 2023 did not have documentation of CPR certification and First Aid training.
These findings were reviewed with facility staff.
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Plan of Correction
Ascend Clinical Services will ensure that at least one staff member on each shift will have their CPR and First Aid training up to date. This will be completed by 10/18/2023. The schedule was adjusted to ensure that at least one staff member on each shift will have their CPR First Aid certification. Moving forward the Ascent Clinical Services compliance officer will conduct quarterly employee file checks for training compliance adherence to ensure that all employees are current and up to date with their required trainings. |