INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 20 -23, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Summit Academy 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 the employee personnel record, the facility failed to document the required period of direct observation and close supervision for one counselor assistant. The findings include: Fourteen personnel records were reviewed on September 20 - 21, 2011. Eleven of the fourteen personnel records reviewed were for the position of counselor assistant. The counselor assistant represented in record # 5, did not include the required supervision documentation. This employee was required to have three months of direct observation and nine months of close observation. Documentation provided included a close supervision note on 3-24-11, and documentation of close supervision from 6-1-11 to 8-10-11. There was no documentation of direct observation and incomplete documentation of close supervision. The lack of documentation was confirmed by the project director and the clinical coordinator on September 23, 2011.
|
Plan of Correction
Employee #5 was required to have three months of direct observation and nine months of close observation, which we did not do because of our misunderstanding regarding his education. This employee began to receive direct observation from a therapist on September 26, 2011 and will begin close observation at approximately March 26, 2012 with a therapist. Education verification procedures by the Human Resources Director will help ensure that this doesn't happen again |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document inspections of the medication storage area.The findings include:On September 20, 2011, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, an inspection of the medication storage area will be completed and documented quarterly by medical personnel and there will be a sign off by the director of medical services and the clinical supervisor. Inspections were reviewed for the months of September 2010 to September 2011. The facility failed to document the inspections of the medication storage area for the time frame that was reviewed. The last documented inspection was completed in September 2010. The facility director and the clinical coordinator confirmed that medication storage area inspections were not documented for the months identified above.
|
Plan of Correction
An inspection of the medication storage area will be completed and documented quarterly by medical personnel and there will be a sign off by the director of medical services and the clinical supervisor. The medication storage area inspection will be completed by the Director of Medical Services no later than November 11, 2011 and the inspection sheet will signed off on by the Clinical Coordinator. The inspection will be added in to our overall organizational compliance audit by the Quality Assurance Director in order to ensure that this task continues to be completed on time. |