INITIAL COMMENTS
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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, Inc. People with Hope/Short-Term Program 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 the review of personnel records and clinical supervision notes, it was determined that the facility failed to ensure that a counselor assistant with a high school diploma received direct observation for the first three months of employment and close supervision the next nine months in one of one applicable personnel record.
Employee #6 was hired as a counselor assistant on November 1, 2019 and was a current employee at the time of the inspection. Per regulation, the employee was to receive direct observation from November 1, 2019 through February 1, 2020 and close supervision from February 1, 2020 through November 1, 2020. The facility failed to document that the employee received any direct observation from November 1, 2019 through February 1, 2020. Additionally, the facility failed to document that the employee received close supervision, specifically one hour of direct observation and one hour of case review.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure that we provide close and direct supervision The Director of People with Hope 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 #6 receives "direct observation and close supervision" the supervisor will document supervision notes until November 1, 2020, per DDAP Policy 704.10: Counselor Assistant Promotion
Persons Responsible:
Division Director
People with Hope Program Director and Supervisor
Timeframe for Completion: 06/30/2020
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