INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 29, 2022 through November 30, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Family Service and Children ' s Aid Society 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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704.9(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, the facility failed to maintain documentation that counselor assistants receive direct observation of the provision of counseling services as part of their close supervision, in two of two applicable records reviewed.
Employee # 5 was hired as a Bachelor's level counselor assistant by the facility on March 21, 2022. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the weekly close supervision.
Employee # 6 was hired as a Bachelor's level counselor assistant by the facility on June 13, 2022. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the weekly close supervision.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Drug & Alcohol Program Director and Clinical Supervisor met on Monday, December 12, 2022, and discussed the policy and deficiency. Program director and clinical supervisor determined that the clinical supervision notes will be altered to include a review of direct observations. In discussion the clinical supervisor identified that they will continue following policy 704.9 C with the addition of direct observation notes. This change will be effective immediately on 12/19/2022. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of six personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one applicable employee received the minimum of 6 hours of HIV/AIDS training and 4 hours of TB/STD training within the regulatory timeframe.
Employee #7 was hired as a counselor on September 7, 2021 and was due to have the communicable disease trainings no later than September 7, 2022. However, the facility provided no documentation of the completion of the HIV/AIDS or TB/STD trainings as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program director met with Employee #7 regarding the deficiency and Employee #7 identified they have signed up for mandatory communicable disease training on January 23, 2023.
Staff will continue following training plans to ensure compliance. Program director and clinical supervisor will oversee and monitor training plans to ensure that staff maintain mandatory trainings. This oversight will be conducted during clinical supervision and documented on clinical supervision notes.
A copy of the training certificate may be sent if requested following the January 23, 2023, training and receipt of certificate of completion.
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709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of facility policy and procedures and a discussion with facility staff, the facility failed to have a follow-up policy which included follow-up services for clients discharged in a type other than successful.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program director and clinical supervisor met to discuss the policy on follow ups on December 12, 2022. At this time both parties agreed to implement policy to ensure follow up with all individuals who were released from treatment, with the exception of incarcerated or deceased individuals. The policy will remain the same for compliant discharges. In addition, a new policy will be implemented to follow up all terminated clients two weeks after termination. All follow ups will be conducted by the clerk typist at each location by telephone. Each follow up will be logged in the agency's discharge data base.
This policy will be implemented following the January 9, 2023, drug and alcohol staff meeting to ensure time to change the written policy, disseminate the new policy to clerk typists, the human resource manager, and the individual counselors.
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