INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 10, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Care Center d/b/a SPHS Care Center 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.
The counselor full time equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility's work week.
Employee #6 was hired as a counselor on August 2, 2017 and was still acting in that position. Employee #6 was reported to have 13 hours per week devoted to their 13 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 13/37.5=.34 (FTE); 13/.34=38, which equals to a client/counselor ratio of 38:1.
Employee #7 was hired as a counselor on May 1, 2021 and was still acting in that position. Employee #7 was reported to have 8 hours per week devoted to their 8 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 8/37.5=.21 (FTE); 8/.21=38, which equals to a client/counselor ratio of 38/1.
Employee #9 was hired as a counselor on July 1, 2019 and was still acting in that position. Employee #9 was reported to have 26 hours per week devoted to their 26 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 26/37.5=.69 (FTE); 26/.69=37.6
8/37.5=.21 (FTE); 8/.21=38, which equals to a client/counselor ratio of 38/1.
Employee #10 was hired as a counselor on August 2, 2021 and was still acting in that position. Employee #10 was reported to have 28 hours per week devoted to their 27 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 28/37.5=.74 (FTE); 27/.74=36.4, which equals to a client/counselor ratio of 36/1.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Counselors will present updates on their caseloads at weekly D&A clinical meetings and review caseloads weekly with Clinical Supervisor. For counselors that cannot attend the weekly Clinical meeting, Supervisor will provide a summary of their caseload that counselor will review. Clinical Supervisor will continue to explore options for additional recruitment of staff. If counselor ratios are maxing out across the board, Program Supervisor will notify Program Director who will put a hold on program referrals until staffing patterns can support. Upon approval the process will begin on April 1, 2022. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory time frame in three out of seven client records reviewed.
Client #3 was admitted on March 9, 2021 and was discharged on January 21, 2022. A comprehensive treatment plan was completed on March 9, 2021 and the next treatment plan update was due no later than May 9, 2021; however the treatment plan update was not documented in the record until May 27, 2021. A treatment update was completed on July 8, 2021 and August 25, 2021; however there were no further updates documented in the record at the time of the inspection.
Client #4 was admitted on April 14, 2021 and was discharged on January 21, 2022. A treatment plan update was completed on October 7, 2021 and the next update was due no later than December 7, 2021; however there was no update documented in the record at time of the inspection.
Client #7 was admitted on September 9, 2021 and was still active at the time of the inspection. A treatment plan update was completed on September 9, 2021 and the next update was due no later than November 9, 2021; however, the treatment plan update was completed on December 16, 2021.
These findings were reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
Treatment Plan Tracker Sheets have been developed so that expiration dates on all clients treatment plans can be referenced every work day. The Program Supervisor will distribute treatment plan tracker sheets to all staff who will be required to keep updated and review every business day to proactively account for approaching treatment plan expiration dates. Upon approval the plan will be executed as early as April 1, 2022. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document case consultations according to the facility's written policy and procedure manual in four out of seven records reviewed. The facility's policy manual indicated case consultations would be documented every ninety days after the client is admitted to treatment and would be completed annually after one year.
Client #1 was admitted on March 9, 2021 and was discharged on August 5, 2021. Client #1 had a case consultation due on June 9, 2021 per the policy and it was completed on July 15, 2021.
Client #3 was admitted on March 9, 2021 and was discharged on January 21, 2022. Client #3 had a case consultation completed on May 27, 2021 and July 29, 2021. A case consultation was due no later than October 29, 2021 per their policy; however, there were no further case consultations documented in the record.
Client #4 was admitted on April 14, 2021 and was discharged on January 21, 2022. Client #4 had a case consultation completed on June 8, 2021 and the next case consultation was due no later than September 8, 2021 per their policy; however there were no further case consultations documented in the record.
Client #7 was admitted September 9, 2021 and was still active at the time of the inspection. A case consultation was due on December 9, 2021 per their policy and was completed on January 13, 2022.
These finding were reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
Case Consultation Tracker Sheets have been developed so that due dates on all clients' case consultations can be referenced every work day. The Program Supervisor will distribute case consultation tracker sheets to all staff who will be required to keep updated and review every business day to proactively account for approaching case consultation due dates. All clients will have case consultations documented in their electronic health record every ninety days after the client is admitted to treatment and then annually after one year. Upon approval the plan will be executed as early as April 1, 2022. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records, the facility failed to provide an Aftercare Plan in one out of two applicable records reviewed.
Client #1 was admitted on March 9, 2021 and was discharged on August 5, 2021. The client record did not contain documentation of an aftercare plan.
This finding was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
Aftercare Plans will be completed in the electronic health record for all clients successfully discharged from services. In addition, Program Supervisor will distribute Discharge Checklist Forms to all staff who will complete them for any client approved for discharge from treatment. These forms include Aftercare Plan and all other required documentation needed for discharge. This form will be submitted to the Program Supervisor prior to staff discharging clients from treatment. Upon approval, the plan will be executed as early as April 1, 2022. |