INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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704.12(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 1, 2015 and an interview with the project director on December 11, 2015, the facility failed to ensure that staff caseloads remained at or under 35:1.The findings include: The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on December 1, 2015 and re-reviewed on December 11, 2015. The form listed five counselors, a clinical supervisor, and a project director/facility director as clinical staff. The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 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 (40), and the total number of clients assigned to the following employees on December 1, 2015, employees # 5 and 7 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 # 5 (a counselor) to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 36 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee #5 had 37 active clients on December 1, 2015.Employee # 5 (36/35 = 1.0285 FTE; 37 clients/1.0285 FTE = 35.9, which is equal to a 36:1 caseload).The number of hours per week devoted by Employee # 7 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 32 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 7 had 37 active clients on December 1, 2015.Employee # 7 (32/35 = .9142 FTE; 37 clients/.9142 = 40.4, which is equal to a 41:1 caseload).These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A part time counselor (30 hours per week) was hired on November 30, 2015 and has completed her orientation and training period on December 14, 2015. She currently has a caseload of 15 clients. Employee #5 and #7 have transferred their excess clients to this counselor. In addition, an second part time counselor (20 hours) will be hired on February 1, 2015. Her orientation and training period will be completed on February 15, 2015. At that point she will be assigned a caseload of 10 clients. Assigned caseloads will be monitored on a monthly basis by the Facility Director. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the 30-day regulatory period as required by Chapter 709 for the partial hospitalization level of care in two of five client records reviewed.The findings include:Ten client records were reviewed on December 11, 2015. Five client records pertained to the partial hospitalization activity, in which they required documentation of treatment plan updates within the 30-day regulatory timeframe. The facility failed to document 30-day treatment plan updates in client records, #2 and 10.Client #2 was admitted into the partial hospitalization level of care on May 26, 2015 and was still an active client as of the date of the on-site inspection. Treatment plan updates were completed on 07/13/2015, 08/13/2015, 10/26/2015, and 11/25/2015. There was a treatment plan update due no later than 09/13/2015; however, there was no update documented in the client record as of the date of the inspection.Client #10 was admitted into the partial hospitalization level of care on March 6, 2015 and was discharged on July 1, 2015. A treatment plan update was completed on 06/22/2015 and the next treatment plan update was to be completed no later than 07/22/2015. However, the treatment plan was not completed until 08/04/2015.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A training on documentation standards was held on December 14, 2015 for all of the counselors. Treatment planning, including required time frames, was emphasized. All counselors were provided with a copy of the documentation standards for future reference. The Facility Director will monitor the charts on a monthly basis to ensure compliance. |