INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on May 14, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Diakon Child and Family Community 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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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of twelve personnel records, the facility failed to document the completion of 12 clock hours of annual training required for counselors in employee #1's employee record.
Employee # 1 was hired as a project director on December 1, 2016 and was still in this position at the time of the inspection. The facility's training year that was reviewed was from January 1, 2019 through December 31, 2019. Employee #1's employee record documented 0 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.11(d) (2) was reviewed with the Project Director on 5/20/20 noting the required clock hours of annual training. Quarterly monitoring of this regulation will be completed by the Facility Director, with written reminders to staff on the training requirements as well as training feedback. All required annual trainings will be completed by the December 31st deadline. Compliance with this standard will be monitored and enforced by the Facility Director. |
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 review of The Staffing Requirements Facility Summary Report, the FTE counselor caseload for five counselors in the outpatient program exceeded 35 active clients.
Employee # 4 was hired as a Counselor on January 4, 2018 and was still acting in that position. Employee #4 was reported to have 26.5 hours per week devoted to their 30 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 26.5/37.5 = .7066 (FTE); 30/.7066= 42.4568, which equals to a client/counselor ratio of 43:1.
Employee # 5 was hired as a Counselor on August 27, 2019 and was still acting in that position. Employee #5 was reported to have 37.5 hours per week devoted to their 36 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 37.5/37.5 = 1 (FTE); 36/1 = 36, which equals to a client/counselor ratio of 36:1.
Employee # 6 was hired as a Counselor on November 18, 2019 and was still acting in that position. Employee #6 was reported to have 27.5 hours per week devoted to their 33 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 27.5/37.5 = .7333 (FTE); 33/.7333 = 45.0020, which equals to a client/counselor ratio of 46:1.
Employee # 8 was hired as a Counselor on January 1, 2017 and was still acting in that position. Employee #8 was reported to have 12 hours per week devoted to their 12 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 12/37.5 = .32 (FTE); 12/.32 = 37.5, which equals to a client/counselor ratio of 38:1.
Employee # 10 was hired as a Counselor on January 14, 2019 and was still acting in that position. Employee #10 was reported to have 37.5 hours per week devoted to their 39 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 37.5/37.5 = 1 (FTE); 39/1 = 39, which equals to a client/counselor ratio of 39:1.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facilities hours of operation 37.5. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.12 was reviewed with all counseling staff on 5/21/20. Case transfers and discharge of inactive cases will be completed by 5/21/20 to ensure that FTE counselor caseload do not exceed 35 active clients. Compliance with this standard will be monitored and enforced by the Facility Director. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of twelve personnel records, the facility failed to provide documentation of an annual performance evaluation for employee # 1.
Employee # 1 was hired as the Project Director on December 1, 2016 and was still in this position at the time of the inspection. An annual performance evaluation was not conducted for the year 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.26(b)(3) was reviewed with the Project Director on 5/20/20 regarding annual written performance evaluations and the 2019 annual performance plan was completed and signed by the Project Director on 5/21/21. Performance evaluations will be completed in writing and signed by all employees on an annual basis. Compliance with this standard will be monitored and enforced by the Facility Director. |