INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 12, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pathway To Recovery Counseling and Educational Services 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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704.8(c) LICENSURE Full Caseload Assignment
704.8. Qualifications for the position of counselor assistant.
(c) In addition to training, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level.
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Observations
During a review of five personnel records on January 12, 2022, the facility failed to complete a positive assessment of the counselor assistant's individual skill level prior to assignment of a full caseload.
Staff #4 was hired on October 18, 2021 and did not have a positive assessment of their individual skill level documented.
Staff #5 was hired on November 1, 2021 and did not have a positive assessment of their individual skill level documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Positive Assessments were completed by the Clinical Supervisor for Staff #4 on 1/21/2022 and for Staff #5 on 1/21/22. The Clinical Supervisor was advised of the necessity of completing positive Assessments for all counselor assistants prior to assigning them full case loads. The Project Director will be responsible for ensuring that the Clinical Supervisor follows though with this policy in the future. |
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 the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility's work week. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE.
Employee #1 was hired as a Project Director/ Facility Director on October 27, 2021 and was still current in that position at the time of the inspection. Employee #1 was reported to have 1 hours per week devoted to their 1 clients on their caseload. The FTE caseload calculation is as follows: 1/40=.025(FTE); 1/.025 =40, which equals to a client/counselor ratio of 40:1.
Employee #3 was hired as a counselor on April 5, 2021 and was still current in that position at the time of the inspection. Employee #3 was reported to have 35 hours per week devoted to their 35 clients on their caseload. The FTE caseload calculation is as follows: 35/40=.875(FTE); 35/.875 =40, which equals to a client/counselor ratio of 40:1.
Employee #4 was hired as a counselor assistant on October 18, 2021 and was still current in that position at the time of the inspection. Employee #4 was reported to have 30 hours per week devoted to their 30 clients on their caseload. The FTE caseload calculation is as follows: 30/40=.75(FTE); 30/.75 =40, which equals to a client/counselor ratio of 40:1.
Employee #5 was hired as a counselor assistant on November 1, 2021 and was still current in that position at the time of the inspection. Employee #5 was reported to have 20 hours per week devoted to their 20 clients on their caseload. The FTE caseload calculation is as follows: 20/40=.5(FTE); 20/.5 =40, which equals to a client/counselor ratio of 40:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency has recently hired two Full Time Equivalent (FTE)staff to bring the client/staff ratio at or below 35/1. Staff #1 started on 2/7/2022 and Staff #2 will start on 2/14/2022. The Project Director will be responsible to ensuring that there are adequate staffing to maintain the required client/counselor ratio at or below 35/1. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical site inspection on January 12, 2022, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
Counseling sessions could be overheard in the hallway outside the counselor's offices.
Front desk personnel could be overheard talking to clients on the telephone in the waiting area.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Agency purchased 10 White Noise Machines. They arrived on February 1, 2022 and were placed in the reception area (waiting room and reception office) and outside of each counseling room. The Project Director will ensure that all staff are utilizing the white Noise Machines during normal business hours. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of fourteen client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated signature of the client in two records reviewed.
Client #3 had an intake, evaluation and referral on October 15, 2021. An informed and voluntary consent for probation was signed by the client on October 15, 2021 but did not include the date.
Client #5 had an intake, evaluation and referral on September 14, 2021. An informed and voluntary consent for a family member was signed by the client on September 14, 2021 but did not include the date.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A meeting was held on January 18, 2022 with the Clinical Supervisor, clinical staff, and the front desk receptionists to discuss the importance of making certain that all signatures are dated. The Clinical Supervisor will be responsible to ensure that all signatures are dated in the chart during weekly random chart reviews. |