INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Greater Philadelphia Asian Social Service Center - Asian Outpatient Counseling Service, 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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704.8(a) LICENSURE Qualifications-Counselor Assistant
704.8. Qualifications for the position of counselor assistant.
(a) A person who does not meet the educational and experiential qualifications for the position of counselor may be employed as a counselor assistant if the requirements of at least one of the following paragraphs are met. However, a project may not hire more than one counselor assistant for each employee who meets the requirements of clinical supervisor or counselor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and Personnel records on November 6, 2017, the facility was not compliant in the employment of their clinical staff. A project may not hire more than one counselor assistant for each employee who meets the requirements of clinical supervisor or counselor.
The project presently employs one clinical supervisor and one counselor. Therefore, a maximum of two counselor assistants should be employed. The project employed three counselor assistants at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/20/2017, program reduced the number of counselor assistant staffing to 2. To ensure this deficiency does not reoccur, program director has developed a protocol for staffing that goes into effect 11/20/2017 to ensure the number of assistant counselor will be (n-1) of the number of counselor. The protocol will allow program to keep a roaster so program can keep track how many counselor program currently has. |
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 six personnel records on November 6, 2017, the facility failed to demonstrate that performance evaluations were conducted semi-annually for all counselor assistants.
Employee #6 was hired on February 15, 2017 as a counselor assistant. She was due to receive a written semiannual performance evaluation based upon measurable performance standards on August 15, 2017. There was no documentation that Employee #6 received a semiannual performance evaluation at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective 12/18/2017, program will ensure all assistant counselors have two semiannual evaluations completed each year to ensure their quality of performance. Clinical supervisor will review clinical skills and work performance twice yearly. |
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 six employee personnel/training records on November 6, 2017, the facility failed to document the required period of close supervision for one of three counselor assistants.
Employee #6 was hired as a counselor assistant on 2/15/2017. Employee #6 was to be under close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment. There was no documentation in the client record showing that Employee #6 was supervised between March 22, 2017 and June 21, 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/20/2017, program no longer employees the clinician with insufficient supervision history. To ensure this does not recur, clinical supervisor has developed a clinical supervision calendar that goes into effect 12/18/2017 to ensure counselor assistants receive sufficient weekly individual supervision, and when necessary, sufficient direct observation. To ensure this deficiency does not recur, clinical supervisor will review clinical supervision calendar weekly during team supervision to remind counselors of expectations. |
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.
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Observations
Based on a review of personnel/training records on November 6, 2017, the facility failed to provide documentation of an individual training plans in one of six personnel records.
Employee #4 was hired on June 13, 2016 and promoted to a Counselor Assistant on September 6, 2016. The facility failed to provide documentation of an Individual Training Plan in the personnel record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/20/2017, program has remedied this deficiency by having the training plan reviewed and signed by the clinician. To ensure this deficiency does not recur, program director has developed implemented a plan to review new hire personnel records 10 days post hire to ensure that appropriate documentation has been completed that goes into effect 11/20/2017. Manager of human-resources department will monitor this review. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report Form (SRFSR), personnel and training records on November 6, 2017, the facility failed to provide documentation of HIV/AIDS and TB/STD training in three of four applicable records reviewed.
Employee #1 was hired as the Project Director June 24, 2013 and was required to complete six hours of HIV/AIDS and 4 hours of TB/STD training by June 24, 2015. Based on the SRFSR completed by the facility on 11/6/2017, employee #1 only completed 3 hours of TB/STD and other health related topic training.
Employee #2 was hired as Lead Counselor on August 3, 2016 and was promoted to Facility Director/Clinical Supervisor on October 30, 2017. Employee #2 was required to obtain six hours of HIV/AIDS and 4 hours of TB/STD training by August 3, 2017 and failed to obtain the training as of the date of the inspection.
Employee #4 was hired on June 13, 2016 and promoted to Counselor Assistant on September 6, 2016. Employee #4 was required to obtain 4 hours of TB/STD training by September 6, 2017 and failed to obtain the training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 2/22/2018 necessary program staff will complete mandated training identified. TB/STI training is scheduled for 1/10/2018. Basic HIV training is scheduled for 2/22/2018.To ensure this deficiency does not recur, new hires will be expected to present evidence of previous mandated treatment completion. Those that do not have the necessary training completed will have the training scheduled for them by clinical supervisor. These training will be scheduled and completed with 1 year of new hire. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of six personnel records on November 6, 2017, the facility failed to document an annual performance evaluation in one of three applicable personnel records.
Employee # 4 was hired on June 13, 2016 and promoted to a Counselor Assistant on September 6, 2016. The annual performance evaluation was due to be completed by September 6, 2017. There was no documentation of the completion of a performance evaluation in this employee's record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/20/2017, program has remedied the deficiency by completing a review with the clinician. To ensure this deficiency does not recur, program director has developed a random personnel record review system, where the records are reviewed every quarterly, and developed an annual review calendar to monitor for upcoming annual evaluation due dates. Manager of human-resources department will monitor this calendar |