INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Ascend Clinical Services 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:
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of personnel records, the facility failed to ensure that the clinical supervisor participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in the position.
Employee #3 was promoted to a clinical supervisor position on January 1, 2024 and was still in that position at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon learning the facility failed to maintain records of the employee's supervision for the first 6 months, The Vice President of Programming initiated documented supervision of the Clinical Supervisor starting on September 25, 2024. The Clinical Supervisor has obtained at least monthly documented supervision from the Project Director until the most recent supervision session on January 6, 2025. The Clinical Supervisor will continue to receive supervision from the Project Director or the Facility Director until the employee has obtained six months of documented supervision (03/25/2025) at which time he frequency of supervision will be assessed according to his performance and skill.
To ensure this deficiency does not continue, The Vice President of Programming will provide the Facility Director training related to 704.6 no later than 02/01/2025. To monitor the effectiveness of this corrective action, the compliance team will audit supervision notes quarterly to ensure Clinical Supervisors receive at least monthly documented supervision during their first six months of employment in the position.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Employee #6 was hired as a counselor on August 1, 2022 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2023 through June 31, 2024. Employee # 6's record only documented 17.75 hours of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 02/01/2025, The Clinical Supervisor will provide documented training and review for all counseling staff related to 704.11(f)(2). To ensure ongoing compliance with 704.11(f)(2), the Facility Director, in collaboration with the Compliance team, will complete quarterly reviews of staff training files. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed 7-10 days following discharge.
Client #7 was admitted on September 14, 2024 and was discharged on December 5, 2024. A follow up was due no later than December 15, 2024; however, it was not completed until January 10, 2025.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the January 29, 2024 licensing inspection.
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Plan of Correction
By 02/01/2025, The Clinical Supervisor will provide documented training for all counseling staff related to the need to document follow-up information in accordance with regulatory standards and organizational policy. To ensure ongoing compliance with 709.93(A)(11), the Clinical Supervisor, in collaboration with the Compliance team, will complete weekly documented chart reviews to ensure follow-up information is documented within timeframes outlined by regulatory standards and organizational policy. |