INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensing inspection that was conducted on February 15, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site inspection, Wyoming Drug and Alcohol Services, Inc. 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 supervisory review and a plan of correction is due on May 13, 2011.
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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 documentation reviewed by supervisory staff, the facility failed to provide a minimum of one full time counselor who provides direct counseling services to every ten clients.
The findings include:
A review of the Staffing Requirements Facility Summary Report provided by the Supervisory Department, the facility failed to have documentation of a ten clients per one full time counselor ratio in the partial hospitalization program.
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Plan of Correction
There was confusion in regards to the number of clients reported. A correct report was returned to the Department of Health approximately one week ago. The ratios are acceptable and requirements are now satisified. The ratio ended up being less than 10/1. |