INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 16, 2008 through December 18, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Serento Gardens 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 and a plan of correction is due on January 21, 2009.
|
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 two counselor assistant personnel records, training records, supervision notes and the staffing requirements summary report the facility failed to provide documentation of direct observation during the close supervision period.
The findings include:
During the survey the facility employed two counselor assistants. Two of two supervisor records failed to document weekly direct observation. Direct observation was required one time a week during close supervision.
Twenty of twenty-five direct observation notes were not documented for counselor assistant hired on June 8, 2008
Seventeen of twenty-three direct observation notes were not documented for a counselor assistant hired on July 1, 2008.
Counselor with a Bachelor's Degree, hired on June 8, 2008 was required to undergo close supervision for six months.
Counselor with an Associates Degree, hired on July 1, 2008 was required to undergo close supervision for nine months.
|
Plan of Correction
Direct observation was conducted but the supervisor included the observation notes in the weekly supervision meeting with the counseling assistant. The supervisor has since separated the direct observation notes from the general supervision notes. |
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.
|
Observations
Based on a review of the staffing requirements facility summary report of December 16, 2008, personnel records and case assignment records the facility exceeded the minimum of one FTE counselor for ten clients
The findings include:
Based on a Full Time Equivalent computation completed on December 18, 2008 utilizing weekly hours and the number of clients assigned to each counselor the FTE is in excess of ten to one.
The FTE computation equated to twelve to one.
|
Plan of Correction
The ratio has been corrected as of this writing. The Vice President and Clinical Supervisor along with the CEO oversaw the process, again working within the Department's formulas
|
704.12(a)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on a review of the staffing requirements facility summary report of December 16, 2008, personnel records and case assignment records of the facility exceeded thirty-five clients for three of nine counselors.
The findings include:
Based on a Full Time Equivalent computation completed on December 18, 2008 utilizing weekly hours and the number of clients assigned to each counselor, three of nine counselors had in excess of thirty five clients.
The clinical director had thirty-eight active clients.
The clinical supervisor had thirty eight active clients.
One counselor had thirty-seven active clients.
|
Plan of Correction
The matter is being resolved through the discharge of cases that were at or near completion. We will continue to monitor caseloads carefully in order to remain in compliance. The Clinical Supervisor is overseeing the process.
Hereinafter, the Clinical Supervisor will, on a monthly basis, monitor the active caseload to assure compliance on the part of each counselor.
|
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
|
Observations
Based on a review of the staffing requirements summary report, the data collection report and License # 402249, with an authorized capacity of 200 the licensee failed to notify the Department of the change of capacity.
The findings include:
Based on a review of the staffing requirements summary report completed and reviewed on December 16, 2008 and an interview with the facility director on December 18, 2008 the facility is in excess of the 200 maximum capacity. At the time of the survey 217 clients were listed on the staffing requirements summary report.
|
Plan of Correction
The CEO will submit a request for an increase in capacity to the Department postmarked no later that Friday, January 16, 2009. |
709.22(b) LICENSURE Governing Body
709.22. Governing body.
(b) If a project is publicly funded, not more than one staff member of the project may sit on the governing body at a designated time.
|
Observations
Based on a review of board meeting minutes, organizational bylaws, annual report, procedure manual, staffing requirement summary report and interviews with the project director and clinical director the publicly funded facility failed to limit one staff member on the governing body.
The findings include:
Board meeting minutes and the staffing summary report reviewed on December 16, 2008 provided documentation that the project director and the clinical director were members of the governing body and both the project director and clinical director were governing body officers.
|
Plan of Correction
The CEO will file request for exception will be submitted to the Department postmarked no later than Friday, January 16, 2009 |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
|
Observations
Based on a review of utilization review and quality assurance policy and procedures documented in the facility manual, the facility failed to provide documentation of a monthly active case list and quarterly quality assurance minutes and reports.
The findings include:
Established facility utilization review and quality assurance policies require a monthly list of active clients and a quarterly quality assurance report. An interview with the project director and clinical director on December 18, 2008 failed to produce a quarterly quality assurance report for the calender year 2008. A monthly utilization report of active clients could not be documented for 2008 or the specific months of April, May, June, July, and November 2008. The April, May, June, July and November utilization reports were requested in order to establish a random list of records to review for the survey of December 16, 2008 through December 18, 2008.
|
Plan of Correction
We regret both the error and the confusion it caused.
The Board Chairperson and the CEO will schedule a Quality Assurance Meeting at the January 26 2009 meeting of the Board of Directors. Reviews will be conducted quarterly thereafter.
The Clinical Supervisor will see to the review of monthly client lists. They will be prepared, reviewed and maintained on file beginning January 30, 2009 with each monthly report of active cases coinciding with the submission of monthly invoices for services, that is, by the 10th day of the following month.
|
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
|
Observations
Based on a review of seventeen client records the facility failed to provide services under the direction of physician in eight of eight records that required physician supervision.
The findings include:
Seventeen client records were reviewed on December 17, 2008 and December 18, 2008. Of the seventeen records eight were required to have physician oversight and review.
Three of three active records reviewed on December 17, 2008 failed to provide documentation of physician supervision.
Record review # 1 - Admitted September 19, 2008 with no documentation of physician review of plans or plan updates
Record review # 2 - Admitted September 25, 2008 with no documentation of physician review of plans or plan updates
Record review # 4 - Admitted October 13, 2008 with no documentation of physician review of plans or plan updates.
Five of five discharged records reviewed on December 18, 2008 failed to provide documentation of physician supervision.
Record review # 9 - Admitted on July 28, 2008, discharged on September 18, 2008 with no documentation of physician review of plans or plan updates.
Record review # 10 - Admitted on February 11 , 2008, discharged on June 26, 2008 with no documentation of physician review of plans or plan updates.
Record review # 13 - Admitted on December 20, 2007, discharged on April 22, 2008 with no documentation of physician review of plans or plan updates.
Record review #14 - Admitted on March 13, 2006, discharged on April 10, 2008 with no documentation of physician review of plans or plan updates.
Record review #15 - Admitted on April 8, 2008, discharged on June 13, 2008 with no documentation of physician review of plans or plan updates
|
Plan of Correction
The Agency Medical Director has been contacted and we are arranging for his signatory reflecting his oversight on the all records that apply to this category. All cases will be brought into compliance by April 1, 2009.
The Clinical supervisor is responsible for follow through. |