INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 7, 2010 through December 9, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Sereonto 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, 2010. .
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on review of personnel records, staffing requirements facility summary report, and conversation with the project director, the facility failed to ensure that one out of four counselors completed 25 clock hours of required training.The findings include:On December 7, 2010 the staffing requirements facility summary report was reviewed along with four personnel records of counselors for documentation of the required 25 hours of training. The staffing requirements facility summary report completed by facility on December 7, 2010 indicated that counselor # 4 had only completed 20 of 25 hours of training. The facility director was asked on December 7, 2010 if this was correct and facility director confirmed that counselor # 4 had not completed 25 hours of training.
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Plan of Correction
Counselors are required to monitor their hours and submit to their training folders. The counselor in question was addressed.
The counselor's supervisor will monitor her training hours quarterly to insure that at least 25% of the hours are completed on time with all hours completed by November 30, 2011 |
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 completed by the facility on December 7, 2010 and an interview with project director and clinical director, the facility failed to ensure that staff caseloads remained at or under 35:1.The findings include: On December 7, 2010, the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed the project director, the facility director, the clinical director, the clinical supervisor, and six counselors for the clinical staff; however, the facility only documented employees # 2, 3, 4, 5, 6, 7, 8, and 9 as having clients on a caseload.The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 37.5 hours per week.Based on the total number of hours per week that the facility reported the employees 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 # 8 and 9 exceeded the allowable maximum 35:1 caseload.The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients 'treatment by the facility's standard workweek.The number of hours per week devoted by Employee # 8 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 35 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 8 had 34 active clients on December 7, 2010.Employee # 8 (35/37.5 = .93 FTE 34 clients/.93 FTE = 37:1 caseload)The number of hours per week devoted by Employee # 9 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 37.5 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 9 had 30 active clients on December 7, 2010.Employee # 9 (31.5/37.5 = .84 FTE 30 clients/.84 FTE = 36:1 caseload)During an interview with the project director on December 7, 2010, the project director confirmed that they had exceeded the allowable maximum caseload of 35:1 for each of the counselors, employees # 8 and 9 above.
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Plan of Correction
The caseloads for counselors #8 and #9 in the survey were corrected to the proper ratio. Cases were selected for transfer and given to counselors with available spots within the stated ratio.
The Clinical Director will conduct ongoing monitoring of the ratios. Monitoring will occur quarterly in quality assurance meetings using the Departments criteria and calculation method. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records and an interview with the project director and clinical director, the facility failed to document annual performance evaluations in two of four personnel records.The findings include:Four personnel records were reviewed on November 8, 2010 for documentation of annual performance evaluations. There were no annual performance evaluations documented in personnel records #1 and 2.Employee # 1 was hired in September 1978 and was due to have an annual performance evaluation by November 16, 2010; however, the last employee performance evaluation was dated November 16, 2009.Employee # 2 was hired in August 1995 and was due to have an annual performance evaluation by June 30, 2010; however, the last employee performance evaluation was dated June 30, 2009.An interview was conducted with the project director and clinical director on December 8, 2010. During the interview, the project director and clinical director confirmed that the performance evaluations mentioned previously were the most recent for each employee.
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Plan of Correction
Neither the Agency Director (me) nor the Vice President had evaluations completed.
The Vice President is the responsibility of the Agency Director. I will complete that evaluation by the target date above.
The Agency Director's evaluation is the responsibility of the Board of Directors. I have notified the Board chair of the deficiency and provided the board executive committee with a copy of my job description and a request to complete the evaluation in the next scheduled Executive Board meeting on January 27, 2011. |
709.26(d)(5)(ii) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(ii) The individual shall be informed, by written copy, of their annual evaluation.
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Observations
Based on a review of personnel records and an interview with the project director and clinical director, the facility failed to document annual performance evaluations in two of four personnel records.The findings include:Four personnel records were reviewed on November 8, 2010 for documentation that staff received a written copy of annual performance evaluations. There were no annual performance evaluations documented in personnel records #1 and 2.Employee # 1 was hired in September 1978 and was due to have an annual performance evaluation by November 16, 2010; however, the last employee performance evaluation was dated November 16, 2009.Employee # 2 was hired in August 1995 and was due to have an annual performance evaluation by June 30, 2010; however, the last employee performance evaluation was dated June 30, 2009.An interview was conducted with the project director and clinical director on December 8, 2010. During the interview, the project director and clinical director confirmed that the employees mentioned above had not received a written copy of a performance evaluation.
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Plan of Correction
Vice President's evaluation was not completed. The Vice President's evaluation is the responsibility of the Agency Director. I will complete that evaluation by the target date above.
The Agency Director's evaluation is the responsibility of the Board of Directors. I have notified the Board chair of the deficiency and provided the board executive committee with a copy of my job description and a request to complete the evaluation in the next scheduled Executive Board meeting on January 27, 2011.
Hereinafter the evaluations will be conducted at the beginning of the fiscal year, July 1, and completed no later than July 31st of each year.
Both the President and Vice President will monitor timely completion. |