INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on May 28, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Gaudenzia Together House 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:
|
Plan of Correction
|
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.
|
Observations
Based on the review of personnel records and clinical supervision notes, the facility failed to ensure that counselor assistants with Bachelor's Degrees received close supervision for at least the first six months in two of two applicable personnel records reviewed.
Employee #7 was hired as a counselor assistant on January 21, 2020 and was a current employee at the time of the inspection. The employee was to receive close supervision from January 21, 2020 through June 21, 2020. The facility failed to document that the employee received close supervision, specifically one hour of direct observation and one hour of case review, during this timeframe.
Employee #8 was hired as a counselor assistant on September 16, 2020 and was a current employee at the time of the inspection. The employee was to receive close supervision from September 16, 2020 through March 16, 2020. The facility failed to document that the employee received close supervision, specifically one hour of direct observation and one hour of case review, during this timeframe.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
To ensure that we provide close and direct supervision The Director of Together House will ensure that all new counselor assistants hired will be provided close weekly supervision per policy 704.8 (a)(5) for the first three months of employment and close direction the next nine months per DOH Policy 704.10: Counselor Assistant Promotion. This will be documented using written supervision notes weekly specifically outlining the direct and close supervision.
To ensure that counselor #7 and #8 receives "direct observation and close supervision" the supervisor will document supervision notes for the remainder of their supervision periods, per DDAP Policy 704.10: Counselor Assistant Promotion
Persons Responsible:
Division Director
Together House Director and Supervisor
Timeframe for Completion: June 30, 2020 |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on the review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document an annual individual training plan for employee # 6.
Employee #6 was hired as a counselor on June 27, 2019 and was a current employee at the time of the inspection. An annual written individual training plan was to be developed no later than July 27, 2019; however, there was no training plan documented for this employee at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will ensure that an individual training plan is developed and documented with all employees on their first date of hire as per our policy. There will be an Annual Training Plan done one year after their hire date and every year thereafter.
The Program Director and/or Clinical Supervisor will complete the new hire and annual training plans. The Human Resource Department along with the CQI Process will monitor due dates for training plans.
The Annual Training Plan for counselor #6 had been completed and was sent to DDAP on May 29, 2020.
Persons Responsible:
Division Director
Together House Program Director and Supervisor
Timeframe for Completion: June 30, 2020
|