INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 17, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Rehab After Work 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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704.12(a)(5) LICENSURE Partial Hosp Ratio
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
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Observations
Based on a review of the facility-submitted Staffing Requirement Facility Summary Report, the facility failed to ensure that the partial hospitalization program had a minimum of one FTE counselor who provides direct counseling services to every ten clients.
The project Full Time Equivalent (FTE) is determined by dividing the total number of hours the project devotes to their clients by the facility's workweek. Then, in order to obtain the project ' s ratio, the total number of clients is divided by the FTE.
The facility's ratio for the partial hospitalization activity was determined as follows: 24/37.5 = .64; 7/.64= 10.93, which equaled to a partial hospitalization program ratio of 11/1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHP secondary staff will have a reduction of 2.5 hours per week at sister facility to allow for an increase of 2.5 hours per week dedicated to PHP level of care resulting in required 10:1 ratio. This will be monitored by Clinical Supervisor. Plan will be implemented on 3/8/21. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure that counseling was provided to a client on a regular and scheduled basis, which is to include individual counseling at least twice weekly, in four of seven partial hospitalization program client records reviewed.
Client #4 was admitted October 29, 2020 and was discharged January 8, 2021. According to the record of service and progress notes the client did not receive individual counseling twice weekly from October 29, 2020 thru December 5, 2020.
Client #5 was admitted June 29, 2020 and was discharged July 25, 2020. There was no documentation in the record of service or progress notes of any individual counseling services occurring between June 29, 2020 through July 25, 2020.
Client #6 was admitted July 15, 2020 and was discharged August 16, 2020. There was no documentation in the record of service or progress notes of any individual counseling services occurring between July 15, 2020 through August 16, 2020.
Client #7 was admitted March 3, 2020 and was discharged April 4, 2020. There was no documentation in the record of service or progress notes of any individual counseling services occurring between March 3, 2020 through April 4, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was identified that primary PHP Counselor was not able to maintain the volume of clients and case management/documentation without additional assistance. We have added another staff person effective 12/13/20 to service PHP level of care. They are considered secondary PHP support and will aid in assurance of individual sessions being conducted weekly. This will be monitored by Clinical Supervisor during routine chart audits for the next 6 months.
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