This report is a result of an on-site licensure renewal inspection conducted on August 12, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Freedom Recovery Center, LLC, 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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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure the FTE counselor caseload in outpatient programs did not exceed 35 active clients for one of one counselor reviewed.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee #3 was hired as a counselor on May 1, 2020. The employee's ratio calculation was as follows: 12/40= 0.3 (FTE); 17/0.3 = 56.66, which equals a client/counselor FTE ratio of 56:1.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and the Compliance Office met on August 15,2024 regarding 704.12(a)(6) Outpatient Caseload. Starting August 15,2024, the Clinical Supervisor will take on 7 additional clients effective August 15.
The Clinical Supervisor will monitor the FTE Counselors caseload as the caseload decreases or increases. When necessary, the Clinical Supervisor will take on additional clients as necessary. |