INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 25, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Casa De Consejeria Drug and Alcohol Counseling Program, Inc. 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(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors and lead counselors, who have not functioned for 2 years as a supervisor in the provision of clinical services, completed a Department-approved core curriculum in clinical supervision in one of one personnel record reviewed. Employee #3 was hired as a lead counselor on October 21, 2022 and did not have clinical supervision experience prior to being hired. There was no documentation of a Department-approved core curriculum at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The lead counselor is registered and will complete the clinical supervisor training provided by DDAP no later than the date indicated above.
In the future, when a lead counselor or clinical supervisor is hired with less than 2 years of supervisory experience the facility director will attempt to schedule an in person training at a state approved site and if unsuccessful then complete the self-guided training provided by DDAP during the first 6 months of employment under this role.
The project director will follow-up with facility director monthly during supervision meetings to ensure completion of training for any new hires for lead or clinical supervisor positions. |
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 personnel records, the facility failed to provide a counselor assistant, who has a high school diploma or GED equivalent, with direct observation by a trained counselor or clinical supervisor while counseling clients for the first 3 months of employment and then for the following 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor in one of one applicable personnel record reviewed. Employee #6 was hired as a counselor assistant on March 6, 2023. There was documentation that weekly individual clinical supervision was occurring; however, there was no documentation that direct observation occurred during the employee's first 3 months of employment. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program director and/or lead counselor will provide direct observation to every clinical session conducted for every counselor assistant hired with a high school diploma or GED equivalent during the first three months of employment. This will be evidenced by the program director and/or co-signing all progress notes and clinical documents with the counselor assistant providing a time to also discuss and review the clinical cases seen for the day.
For employee #6 this will take affect immediately until June 6 when he will transition from direct observation to close supervision.
The project director will conduct and in-service training with facility director and lead counselor to discuss staffing requirements and regulations for each category of counselor under the state guidelines including supervision requirements for each. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's May 2022 through March 2023 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts. The facility's hours of operation are Monday through Thursday 9:00AM - 5:00PM-(5:00PM through 8:00PM telehealth) and Friday 9:00AM - 3:00PM. All the fire drills conducted, during the reviewed period, were completed at 9:00AM. None of the drills were conducted during the facility ' s afternoon and evening hours of operation. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will review and retrain the facility director on the correct way to conduct a fire drill and complete the fire drill logs. This includes, but not limited to exit route used, the amount of time it took for evacuation or whether the fire alarm/smoke detector was operative, and alternating days and times covering our operating hours. The facility director will set monthly reminders to conduct fire drills and complete the fire drill log correctly by filling in and checking off the necessary information required after conducting the fire drill. The facility director will also set monthly check-ins and review of documents to ensure its appropriate completion. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities. This is a repeat citation from the May 3, 2022 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has contacted an independent public accountant who will have our 2021 financial audit completed by the date indicated above. The Executive Director will make sure to secure the commencement of future audits no later than May 31 through an engagement letter and completed by June 30. |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on a release of information form in one of seven client records reviewed.Client #4 was admitted on July 7, 2022 and was discharged on January 19, 2023. A blank release of information form was signed and dated by the client on July 7, 2022; however, the name of the person, agency or organization was not documented on the form. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will hold an in-service training to discuss timely revisions and checks of releases of information in order to prevent expiration, lapses of time while a client is active in our program, appropriate completion of whom the release is for, client and witness signatures, and dates. The training will focus on including the correct signatures with dates for the clients and witnesses. Active charts will be audited in order to rectify any ROIs out of compliance and active clients will sign a new ROI.
The in-service will also discuss essential information and forms which will facilitate compliance to general guidelines of client confidentiality framed by 4 Pa Code 255.5 regulations and 42 CFR Part 2, including the Health Insurance Portability and Accountability Act (HIPPA) The nature of the release and the circumstances by which the information may be released, the specific content and limited nature of the information to be disclosed, to whom specifically, the purpose of the disclosure, the method of releasing the information as well as the timeframes for the release, signature of client and witness, date of signatures and whether the client has received a copy. This will be completed by 7/15/23.
Clinical staff will continue to attend recommended Department of Health trainings and provide documentation in areas such as confidentiality and client record keeping. This will be monitored by the Project Director and the facility director on an annual basis. |