D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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COVE FORGE BEHAVIORAL HEALTH SYSTEM AT WILLIAMSBURG
202 COVE FORGE ROAD
WILLIAMSBURG, PA 16693

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Survey conducted on 05/07/2020

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 7, 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, Cove Forge Behavioral Health System at Williamsburg 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 a review of personnel records on May 7, 2020, the facility failed to provide employee #9, whom was hired as a counselor assistant with a high school diploma on July 1, 2019 and still a counselor assistant at the time of inspection, with direct observation for the first three months of her employment. These findings were discussed with facility staff during the inspection process.	Plan of Correction Employee #9 will received 3 months of direct observation from the detox clinical supervisor prior to moving back into the close supervision phase of her counseling career. Her direct observation period will begin on May 26, 2020 and end on August 26, 2020. Moving forward, all counselor assistant candidates will be required to turn in a copy of their college diploma showing full completion of requirements set forth by the university they are graduating from prior to their hire date.