INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 13 - 15, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. - Crossroads 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records and discussions with the administrative coordinator, the facility failed to document the clinical supervisor participated in monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in that position in one of one personnel record.
The findings include:
Personnel records were reviewed on November 13, 2012. One of the personnel records reviewed was that of a clinical supervisor. This personnel record required the documentation of monthly meetings between the clinical supervisor and their supervisor for the first six months of employment in that position. The facility failed to document monthly supervision meetings in personnel record # 3.
Employee # 3 was hired on July 3, 2012. Monthly supervision meetings were required to take place from July 2012 to current. There was no documentation of monthly supervision meetings in the personnel record or for review of employee # 3.
The findings were reviewed with the administrative coordinator and were not disputed.
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Plan of Correction
Division Director will review supervision requirements for clinical supervisors in the next scheduled management team meeting in December 2012.
Personnel requirements regarding supervisory notes will be reviewed by executive assistant monthly and findings will be reported in monthly management team meetings. |
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 the employee personnel record, the facility failed to document the required period of close supervision for one counselor assistant.
The findings include:
Ten personnel records were reviewed on November 13, 14, and 15, 2012. Three of the ten personnel records reviewed were for the position of counselor assistant. The counselor assistant represented in record # 4, only had two months of supervision documented. April 16, 2012 to June 28, 2012 was documented. The supervision from July 2012 to October 2012 was missing. This employee was required to receive six months of close supervision.
The findings were reviewed with the administrative coordinator, and were not disputed.
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Plan of Correction
Division Director will review supervision requirements of all counselor assistant positions with all members of the management team in the next scheduled management team meeting in December 2012.
Executive Assistant will monitor personnel files and supervisory notes monthly and report findings in the monthly management team meeting to assure proper supervision is documented. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel/training records and discussions with the administrative coordinator, the facility failed to document that the counselor obtained 25 hours of training for the 2011 training year in one of two personnel records.
The findings include:
Personnel/training records were reviewed on November 13-15, 2012. Two of the personnel/training records reviewed were for counselors who were required to obtain training hours for the 2011 training year. The facility failed to provide documentation of the 25 hours required in one of the counselor personnel/training records, #10.
Employee # 10 was employed as a counselor for the entire 2011 training year. There were 19 hours of training documented for 2011. This is below the required amount of 25 hours of training.
The findings were reviewed with the administrative coordinator and were not disputed
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Plan of Correction
Division Director will review all counselor training requirements with all management team members during the management team meeting in December 2012.
Division Director will review and document status of trainings acquired by counselors in monthly Program Meeting with facility director.
Executive Assistant will prepare and review status of all staff training hours acquired and needed on a quarterly basis during the management team meeting. |