INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the May 16, 2011 licensure renewal inspection. The follow-up inspection was conducted on August 12, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Malvern Institute 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(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records and discussion with the project/facility director it was confirmed that the facility failed to demonstrate that performance evaluations were conducted semi-annually for counselor assistants.
The findings were:
Employee record #1 contained no performance evaluation for December 2010. The counselor assistant was hired on 11-16-2009 as an administrative coordinator. On 9-11-2010 changed positions and became a counselor assistant. No performance evaluation was documented in the staff record. An interview with staff confirmed these findings.
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Plan of Correction
Employee #1 is presently on vacation returning 8/31/11. Upon her return and by 9/2/11 a review will be conducted with her. Additionally, Semi-annual reviews will be conducted for all counselor assistants going forward. This will be completed by the Clinical Supervisor. This will be tracked and monitored by the Executive Director. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records and an interview with the project/facility director, the facility failed to document that a staff member, who is a counselor assistant, is working toward meeting the qualifications for the position of counselor.
The findings include:
Personnel records were reviewed on August 12, 2011. One personnel record pertained to the position of counselor assistant. Per regulation, a counselor assistant shall document to the facility director that she is working toward counselor status. This information shall be documented upon completion of each calendar year. The facility failed to provide documentation that the counselor assistant is working toward meeting the qualifications for the position of counselor in staff record #1.
Employee #1 was hired on September 11, 2010 in the counselor assistant position. Employee # 1 did not provide documentation by December 31, 2010 that she is working toward counselor status.
A staff interview verified this information.
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Plan of Correction
Employee #1 is presently on vacation returning 8/31/11. Communications with her have confirmed that she if planning to continue her educational goals. Upon her return and by 9/1/11 her documentation of this intention and her educational goals will be documented in her file. Educational goals of Counselor Assistants will be submitted in writing to the Executive director by December 1st of each year. This date coincides with their annual review, which is conducted in the month of January. All Counselor Assistants have been made aware of this policy in writing. |