Observations
Based on the review of employee personnel, administrative documentation, and an interview with the Vice President of Quality Improvement, the facility failed to document monthly supervisory sessions for each new supervisor for the first six months of employment.
The findings include:
On January 31, 2011 and February 1, 2011 personnel records were reviewed. The "Staffing Requirements Facility Summary Reports" was reviewed. Employee record # 3 was listed as the clinical supervisor with the start date of 5/24/2010. The record did not have any documentation of supervisory notes for the initial six months of employment for employee #3. An interview with the Vice President of Quality Improvement on January 31, 2011 at 12:55 p.m. confirmed that the clinical supervisor did not have documented monthly supervisory meetings with their supervisor for the first six months of employment in that position.
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Plan of Correction
Pennsylvania Counseling Services submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State laws relating to drug and alcohol treatment. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or an admission of past or ongoing violations of applicable regulatory requirements.
The Vice President of Quality Improvement and Director of Quality Improvement will ensure that the clinical supervisor receives monthly supervision with his/her supervisor to discuss his/her duties and performance. The monthly supervision meetings will occur for 6 months starting March 2011 and frequency of meetings thereafter will be based upon the clinical supervisor's skill level. Documentation of these meetings will be kept in the personnel file.
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