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 & 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 one of one applicable record 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.
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. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client #4 was admitted on April 11, 2022 and was discharged on September 15, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on May 13, 2022, with no client signed consent to release information form signed by the client.
This is a repeat citation from the November 18, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Drug and Alcohol clinical supervisor will meet with Client #4's primary counselor and discuss the citation within the next week during clinical supervision. Clinical supervisor and Program Director will address obtaining release of information prior to sending documentation pursuant to confidentiality policies during the drug and alcohol program meeting on January 9, 2023. Clinical supervisor will conduct randomized chart checks to monitor status of compliance. Counselors will also implement weekly chart checks on peers to reduce possibility of oversight. In addition to weekly monitoring, the clinical supervisor will address confidentiality policy with each individual counselor during weekly supervision to ensure ongoing compliance. |
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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