INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 7, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Creative Health Services 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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704.9(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 employee personnel records reviewed, the facility failed to provide documentation of supervision to include one hour of direct observation for two applicable counselor assistants reviewed. Employee # 10 was hired as a counselor assistant on April 14, 2023, and was still in this position at the time of the inspection. Employee #10 did not have a qualifying bachelor ' s degree and was reviewed off of their high school diploma which indicates they 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. There was no documentation of direct observation in the record. Employee # 11 was hired as a counselor assistant on December 11, 2023, and was still in this position at the time of the inspection. Employee # 11's did not have a qualifying bachelor ' s degree and was reviewed off a high school diploma which indicates they 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. There was no documentation of direct observation in the record. Direct observation is defined by regulation as follows: " In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities " .In accordance with 28 Pa. Code 704.9(a), a counselor assistant must be supervised by a fulltime clinical supervisor or a full-time counselor. The fully qualified clinical supervisor or counselor is then responsible for weekly supervision notes relating to the counselor assistant.Clear documentation in the weekly notes and in the pertinent client charts must also demonstrate that direct observation is occurring. These notes must be current and are to be made available to the Licensing Specialist or other Department of Health staff upon request.Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " .Supervision is to focus on the development of the counselor assistant ' s clinical skills. Weekly supervision notes must clearly demonstrate that close supervision is occurring. The weekly notes should also provide a reference to the charts that will demonstrate that at least one hour per week of direct observation is being conducted.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 7, 2024, Program Director will ensure that direct observation of staff employed as a Counselor Assistant, will receive Direct Observation which will be clearly documented in supervision notes and individual progress notes according to 704.9 |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on one of two applicable client records reviewed, the facility failed to provide an aftercare plan upon completion of treatment in one client record.Client # 7 was admitted on April 3, 2023, and was discharged on August 18, 2023. There was no aftercare plan documented in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 7, 2024, Program Director will train staff and monitor charts to verify Aftercare Plans are being completed, if applicable, per 709.93. |