INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on January 10, 2012 through January 13, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing 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.
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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 current client census information and clinical staff hours, the facility failed to ensure that the staff to client ratio remained at or below one full time equivalent (FTE) counselor for every ten clients.The findings include:The current client census information and clinical staff hours were reviewed on January 13, 2012. Regulations for partial hospitalization activities require one FTE counselor for every ten clients. Currently there are three part time counselors providing a combined total of 24.5 clinical hours per week at this facility and there are eight active clients in the partial hospitalization activity. Based on this information, the client to counselor ratio is 13:1.\ The project director and other staff were interviewed throughout the three day inspection and again on January 13, 2012. The project director confirmed that the client to counselor ratio is 13 clients to one FTE counselor.
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Plan of Correction
At the present time, our PHP census is 3 clients which keeps us in compliance with the staff to client ratio. We will remain mindful of the 1:10 ratio for the PHP and will have a capacity limit of 6 clients who will actively participate in the program at one time. At the beginning of each month, a print-out of active and pending clients for each counselor will be provided to the Clinical Director by the fiscal department. Using this monthly print-out, the Clinical Director will monitor staff caseloads to ensure compliance. |
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.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form and client records, the facility failed to ensure that staff caseloads remained at or under 35:1.The findings include: The Staffing Requirements Facility Summary Report form was completed by the facility and reviewed on January 11, 2012 and January 12, 2012. The form listed the project director, the facility director, the clinical director, the clinical supervisor, and six counselors for the clinical staff.The facility's standard work week reported by the facility on the Staffing Requirements Facility Summary Report form is 37.5 hours per week.Based on the total number of hours per week that the facility reported the clinical staff devoted to their clients, the total number of hours in the facility's standard work week 37.5, and the total number of clients assigned to the following employees on December 7, 2010, employees # 4 and 6 were responsible for client to counselor caseloads that exceeded the allowable maximum of 35:1.The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the number current outpatient clients. The FTE is determined by dividing the number of hours devoted to the clients 'treatment by the facility's standard workweek for each counselor/counselor assistant.The number of hours per week devoted by Employee # 4 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 23 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 4 had 23 active clients on January 12, 2012Employee # 4 (23/37.5) = .613 FTE 23 clients/.613 FTE = 38:1 (caseload)The number of hours per week devoted by Employee # 6 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 31.5 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 6 had 30 active clients on January 12, 2012Employee # 4 (31.5/37.5 = .84 FTE 30 clients/.84 FTE = 36:1 (caseload)Interviews with the project director throughout the three day survey and on January 13, 2012 confirmed the excessive caseloads for two of eight counseling staff.
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Plan of Correction
We have re-assigned clients from the caseloads of counselor #4 and counselor #6 to two counselors who had more flexiabliity within their schedules (bringing into the office these two school based counselors who were collecting partial unemployment because their school based referrals have declined). At the present time, counselor #4 has 20 active clients on her caseload and counselor #6 has 27 clients on her caseload. We will remain mindful of the number of clients each counslor can maintain in order to remain compliant with the ratio standard. At the beginning of each month, a print-out of active and pending clients for each counselor will be provided to the Clinical Director by the fiscal department. Using this monthly print-out, the Clinical Director will monitor staff caseloads to ensure compliance. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records and a review of the project's policy and procedure manual, the facility failed to document a complete client record in two of six client records.The findings include:Facility policy reviewed on January 11, 2012 requires documentation of client follow-up within thirty days of discharge.Six discharged records were reviewed on January 12, 2012. Two of six records failed to document follow-up activities within thirty days of discharge as required by facility policy. Client # 14 was admitted on 12/10/10 and discharged on 8/1/11. Follow-up information is to be documented within 30 days of completion of treatment. Follow-up was documented on 10/15/11.Client # 15 was admitted on 04/21/1 and discharged on 8/15/11. Follow-up information is to be documented within 30 days from completion of treatment. Follow-up was documented on 10/28/11. The clinical supervisor, chief executive officer and chief operating offices confirmed the follow-up information was not documented according to facility policy.
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Plan of Correction
The issue of client follow-up was discussed with the counseling staff and the following procedure has been put in place: upon completing the discharge of a client, the counselor will submit a form with the client's name, address, and discharge date to the receptionist. This form will be kept in a dated file which will be reviewed on a weekly basis. Follow-up letters, with accompanying satisfaction surveys, will be sent each week to clients who have been discharged during the previous 20 days. The clinical director will montior this procedure on a monthly basis to insure compliance. |
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).
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Observations
Based on a review of client records, the facility failed to provide physician signatures on treatment plans and treatment plan updates in four of six client records. The findings include: Fifteen client records were reviewed on January 11, 2012 and January 12, 2012. Six of the fifteen records were authorized for medical assistance payment for services and required a physician signature on the treatment plans and the treatment plan updates. Physician signatures were not documented on the treatment plans and treatment plan updates in client records #'s 1,2 ,3 and 4. In the discussion with the President/Chief Executive Officer,Vice President/ Chief Operations Officer and clinical director, treatment plans are delivered to the facility's medical director. The medical director fails to return the treatment plans and treatment plan updates in a timely manner to meet compliance.
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Plan of Correction
We are currently delivering and retrieving the the Treatment Plan and the Treatment Plan Updates to the Medical Director on a daily basis. This practice has helped alleviate the problem of the Medical Director not reviewing and returning the plans within the required time frame. The Vice President and Chief Operating Officer will be responsibe for delivering and retrieving the Treatment Plans. In an effort to avoid a citation in the future, the Vice President and Chief Operating Officer will note the dates that the plans are delivered and will continue to work with the physician to ensure that the plans are reviewed and signed in a timely fashion. |