INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 15, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Counseling and Adoption 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 inspection:
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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 review of The Staffing Requirements Facility Summary Report, the FTE counselor/client caseload in the outpatient program exceeded 35 active clients.
Employee # 3 was hired as a counselor on February 27, 2023 and was still in this position at the time of the inspection. Employee #3 was reported to have 2 hours per week devoted to their 2 clients on their caseload.
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. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE.
The FTE counselor's caseload calculation is as follows: 2/38 = .052(FTE); 2/.052 = 38.46, which equals to a client/counselor ratio of 38:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client/staff and client/counselor ratios will be followed by CCCAS. The FTE counselor caseload for counseling in an outpatient setting may not exceed 35 active clients. CCCAS's compliance with standards will be continuously monitored by the Director of Counseling. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of all staff being instructed on the use of the fire extinguisher upon employment.
Employee # 1 was hired as the project director/facility director on January 2, 2023 and was still in this position at the time of the inspection. Fire extinguisher training did not occur until March 14, 2023.
Employee # 3 was hired as a counselor on February 27, 2023 and was still in this position at the time of the inspection. Fire extinguisher training did not occur until March 13, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, within the first seven days of employment, the Director of Counseling will ensure that all new hires receive fire safety training. Relias will continue to be used by CCCAS for training purposes. Relias administrators will monitor employee training deadlines and make sure that fire safety training deadlines are modified to fully comply with the standard. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill log for the months of May 2022 through January 2023, the facility failed to provide documentation of a fire drill being conducted the month of September 2022.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 12, 2022 annual licensing inspection.
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Plan of Correction
The Chief Executive Officer will ensure that unannounced fire drills occur at least once every month effective immediately. The Fire Drill Log will continue to be used by CCCAS to record fire drills in order to increase safety and preparedness, as well as compliance with standards. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies upon employment.
Employee # 1 was hired as the project director/facility director on January 2, 2023 and was still in this position at the time of the inspection. Emergency training did not occur until March 13, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Executive Officer will, starting immediately, make sure that every employee is trained to carry out tasks in an emergency. CCCAS will continue using Relias for instructional and training purposes. Administrators within Relias will monitor employee training deadlines and ensure that those for new hires are changed to completely adhere to the standards. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the facility's fire drill log for the months of May 2022 through January 2023, the facility failed to prepare alternate exit routes to be used during fire drills. All exits documented were using the "rear door".
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Executive Officer will ensure that unannounced fire drills occur at least once every month effective immediately. Staff will practice using alternative escape routes. The Fire Drill Log will record primary and secondary exit routes. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client record # 1.
Client # 1 was admitted on March 2, 2023 and was still active at the time of the inspection. A review of client records and discussion with facility administration indicated funding was being provided to the client. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 12, 2022 annual licensing inspection.
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Plan of Correction
With immediate effect, the Director of Counseling will ensure that clinicians are obtaining informed and voluntary consent for the disclosure of their information to a funding source. The CCCAS policy and procedure surrounding the release of information was reviewed will all clinicians. Each clinician is familiar with the requirements for information disclosure and will secure informed, voluntary consent during the initial intake appointment. |
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.
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Observations
Based on two of three applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records # 2 and # 5.
Client # 2 was admitted on June 22, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on August 9, 2022. A treatment and rehabilitation plan update was due no later than October 9, 2022; however, a treatment and rehabilitation plan update did not occur until December 3, 2022. A treatment and rehabilitation plan update was due no later than February 3, 2023; however there was no documentation of a treatment plan update in the client record.
Client # 5 was admitted on September 6, 2022 and was discharged on December 7, 2022. A treatment and rehabilitation plan was developed on September 21, 2022. A treatment and rehabilitation plan update was due no later than November 21, 2022; however, there was no documentation of a treatment plan update in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CCCAS has evaluated and revised their Quality Improvement Plan, which is now in effect. It is ensured that sessions are client-centered by measuring the timeliness of treatment plan updates. The Director of Counseling is responsible for overseeing treatment plan evaluations and making sure revisions are made to the plans at least once every sixty days. The treatment plans are reviewed with clinicians during clinical supervision. This measurement-based care provides insight into treatment progress, highlights ongoing treatment targets, reduces symptom deterioration and improves client outcomes. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on two of two applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur within thirty days after discharge by letter.
Client # 6 was admitted on March 9, 2022 and was discharged on May 11, 2022.
There was no follow-up information available in the client record.
Client # 7 was admitted on May 27, 2022 and was discharged on July 14, 2022.
There was no follow-up information available in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 12, 2022 annual licensing inspection.
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Plan of Correction
The Quality Improvement Plan for CCCAS has been reviewed and updated to include measuring the counseling program's success by gathering information on the number of clients who say the program has been helpful to them. Clients are invited to complete Client Satisfaction Surveys, which are distributed to clients within three months after discharging from treatment. The Director of Counseling is responsible for ensuring clients receive the Satisfaction Surveys. Effective immediately, CCCAS will implement this approach to help boost client satisfaction and achieve better outcomes. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to display a telephone number to the general public for emergency purposes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CCCAS acknowledges that emergency management is a crucial component of behavioral health care. For emergencies that can arise outside of regular business hours, Crisis Services number and 911 have been prominently placed for the general public. |