INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 25 and 26, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Genesis house, Inc, Williamsport 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 and a plan of correction is due on February 20, 2010.
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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 summary report form submitted by the facility on January 25, 2010 and a discussion with the Project Director and the Facility Director on January 25, 2010, the facility failed to ensure that staff to client rations remained at or under 35:1.
The findings include:
Four counselor caseloads were reviewed in January 25, 2010. Based on the number of hours the employees worked at this facility, and the number of clients on the counselors' caseload, two counselors exceeded the caseload of 35:1. The counselors represented by personnel records # 1 and 4 each had a caseload under 35:1. The counselor represented by personnel record #2 had a caseload of 42:1 and the counselor represented by personnel record #3 had a caseload of 42:1; both caseloads exceeded the maximum of 35:1.
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Plan of Correction
Project Director will review finding with the facility director on 2/5/10 to develop and implement a plan for adjusting client case loads within the facility to meet the staff to client ratio standard.
Facility director will monitor staff to client ratios moving forward and will report to project director on a weekly basis to ensure compliance by 2/12/10. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of administrative policies and procedures and a discussion with the Project Director on January 25, 2010, the facility failed to provide documentation of a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric and medical coverage.
The findings include:
The administrative policies and procedures were reviewed on January 25, 2010. The facility was unable to document a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric and medical coverage. The Project Director reported a referral agreement had been sent to a local hospital but the updated agreement had not been returned by the hospital.
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Plan of Correction
Project director will schedule a face to face meeting with the administration of Susquehanna Health System to secure a signed referral agreement for 24-hour emergency medical and psychiatric services by 2/19/10. Project director will place signed agreement in the referral agreement binder for licensing review. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the staffing requirements facility summary report and active client list, the facility failed to notify the Department of a change in authorized maximum capacity.
The findings include:
The staffing requirements facility summary report was reviewed on January 25 & 26, 2010. The summary report, signed by the Project/Facility Director, indicated the facility had 194 current clients. The facility is licensed by the Division for a maximum client capacity of 192.
The Facility Director generated an active client list on January 25, 2010. The active client list had 194 current clients. The Facility Director acknowledged that the facility was currently over the authorized client capacity of 192.
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Plan of Correction
The facility director will begin reviewing the facility's current client case load numbers with the project director on a weekly basis to ensure awareness of when the facility may be approaching maximum capacity by 4/30/10. If the client capacity is approaching the facility's maximum capacity the project director will either request an increase in maximum capacity from the department or notify the facility director to stop taking any client referrals until such time as the facility's client case load numbers allow. The facility director will monitor weekly by 4/30/10 to ensure consistent compliance. |