INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 8-9, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, SPHS Behavioral Health 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 twelve personnel records, the facility failed to ensure that three counselor assistants were counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #10 was hired as a counselor assistant on September 16, 2021. Employee #10 has a bachelor's degree and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for the first six months of employment. Employee #10 did not receive close supervision from date of hire until the time of inspection. Direct supervision did not occur between September 16, 2021, through January 5, 2022.
Employee #11 was hired as a counselor assistant on November 16, 2021. Employee #11 has a bachelor's degree and may only counsel clients under the close supervision of a trained counselor or clinical supervisor for the first six months of employment. Employee #11 did not receive close supervision from date of hire until the time of inspection. Direct supervision did not occur between November 16, 2021, through January 2, 2022.
Employee #12 was hired as a counselor assistant on November 16, 2021, Employee #12 has a bachelor's degree and may only counsel clients under the close supervision of a trained counselor or clinical supervisor for the first six months of employment. Employee #12 did not receive close supervision from date of hire until the time of inspection. Direct supervision did not occur between November 16, 2021, and January 7, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An internal policy has been created to ensure both proper assessment of a counselor assistants skill level, in addition to close supervision, as defined by DDAP to be "Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week". This policy included developing a Direct Observation Supervision Log which will be completed with the Assist following each observed session. Additionally, the Trained Counselor/Supervisor and/or Team Lead will sign off on progress notes indicating that the session was directly observed. This Direct Observation will occur in addition to weekly supervision formally documenting case review, evidenced by individual Supervision Logs.
A counselor assistant will not be assigned a full caseload until a positive assessment is reflected on the evaluation.
This policy will be implemented effective March 1, 2022.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven client records reviewed.
Client #2 was admitted on June 3, 2021 and was discharged on October 6, 2021. A treatment plan update was completed on July 7, 2021 and the next treatment plan update was due no later than September 7, 2021; however, there was no update documented in the record at the time of the inspection.
Client #6 was admitted on September 8, 2021 and was still active at the time of the inspection. A treatment plan was completed on September 8, 2021 and the update was due no later than November 8, 2021; however, the treatment plan update was completed on December 13, 2021.
Client #7 was admitted on June 8, 2021 and was still active at the time of the inspection. A treatment plan update was completed on August 11, 2021 and the next update was due no later than October 11, 2021; however, the treatment plan update was completed on December 9, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinicians will be formally retrained by the Clinical Director on completion of plans of care, emphasizing the necessity of submitting them in a timely fashion. This training will take place before April 1, 2022 and will occur on an as needed basis thereafter. Completion of this training will be evidenced by Training Certificates provided at the completion of the training. Each clinician will receive a hard copy of the Plan of Care Training to use as reference for Plan of Care review and update timeframes. During scheduled supervisions, each clinician will also review with Supervisor and/or Team Lead plans of care which are coming near the date for review/update. This will be evidenced by and documented on Supervision Logs. |