INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 16 - 18, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Center for Psychiatric And Chemical Dependency Services 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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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of the policy and procedure manual and other administrative documentation, the project failed to appropriately identify a project director who has responsibility for the overall management of the project.
The findings include:
The policy and procedure manual was reviewed on July 30, 2012. Personnel records were reviewed on July 30, 2012. The employee's job description for the person listed as the project director was requested on July 30, 2012 and again on July 31, 2012. The facility did not provide documentation that demonstrated the person listed as the project director performed the duties of the project director.
The findings were discussed with Quality Assurance personnel on July 30, 2012 who disagreed with the findings that the person listed as the project director did not perform the duties of the project director. However, the facility did not produce documentation to demonstrate that the person identified as the project director performed those duties and/or had the appropriate authority.
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Plan of Correction
Under the direction of the Governing body/Executive management team, the Clinical Administrator of Addiction Medicine Services (AS) is the Project Director. AS meets the qualifications of Project Director for Western Psychiatric Institute and Clinic Addiction Medicine Services as stated in applicable DDAP regulations and legal authority requirements for program director position.
- Providing primary operational leadership for the programs
- Having responsibility for the overall management of the project and staff
- Her education and experience meets all requirement of chapter 704
- Can execute contracts, establish wage scales, approve personnel policies, manage fiscal matters, and perform related duties related to Addiction Medicine Services.
- Providing periodic scheduled as well as annual summary to Western Psychiatric Institute and Clinic executive management team as the governing body for WPIC
WPIC's Director of TJC and Ambulatory Regulatory Compliance will submit to DDAP by September 28, 2012 the corrected staffing grids for each WPIC facility licensed by DDAP indicating the Project Director as A.S.and a letter from the CEO asserting AS meets the qualifications of Project 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 a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
The Staffing Requirements Facility Summary Report form was reviewed on July 16, 2012. The form listed three clinical supervisors and ten counselors. Nine of these counselors are listed as having clients on their caseload. The facility failed to maintain caseloads at 35 active clients to one FTE (full-time equivalent) counselor in five of nine counselor caseloads.
The facility's standard work week, as documented on the Staffing Requirements Facility Summary Report, was 40 hours per week.
Based on the total number of hours per week that the facility reported the counselors devoted to their clients, the total number of hours in the facility's standard work week (40), and the total number of clients assigned to the counselors on July 16, 2012, employees # 5, 9, 13, 14 and 15 exceeded the allowable maximum 35:1 caseload.
Employee # 5 is a counselor and was hired on October 10, 2011. Employee # 5 has a caseload of 43 active drug and alcohol clients and dedicates 40 hours per week to these clients. Employee # 5 (40 clinical hours/40 standard work week = 1 FTE 43 clients/1 FTE = 43:1 caseload)
Employee # 9 is a counselor and was hired on July 5, 2011. Employee # 9 has a caseload of 30 active drug and alcohol clients and dedicates 19 hours per week to these clients.
Employee # 9 (19 clinical hours/40 standard work week = .475 FTE 30 clients/.475 FTE = 64:1 caseload)
Employee # 13 is a counselor and was hired on November 9, 2012. Employee # 13 has a caseload of 40 active drug and alcohol clients and dedicates 39 hours per week to these clients. Employee # 13 (39 clinical hours/40 standard work week = .975 FTE 40 clients/.975 FTE = 41:1 caseload)
Employee # 14 is a counselor and was hired on June 14, 2010. Employee # 14 has a caseload of 37 active drug and alcohol clients and dedicates 40 hours per week to these clients. Employee # 14 (40 clinical hours/40 standard work week = 1 FTE 37 clients/1 FTE = 37:1 caseload)
Employee # 15 is a counselor and was hired on June 27, 2011. Employee # 15 has a caseload of 35 active drug and alcohol clients and dedicates 20 hours per week to these clients. Employee # 15 (20 clinical hours/40 standard work week = .5 FTE 35 clients/.5 FTE = 70:1 caseload)
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Under the direction of the Clinical Administrator or her designee, the staff patient ratio will be reviewed weekly in supervision beginning 9/1/12. Identification of clients ready for discharge or transitioned to alternate LOC will be identified. Beginning 9/1/12, the Program Director will review all clinician caseloads weekly to identify areas of inconsistency in caseload numbers and clients who can be transferred to clinicians with lesser caseloads. Effective 9/1/12, the Program Director will review with the Clinical Administrator intake and new admission numbers and reduce access as needed to maintain caseload numbers. Caseloads will meet staff patient ratio of 35:1 by 10/18/12. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted on July 16, 2012, the facility failed to ventilate bathrooms by an exhaust fan or window.
The findings included:
A physical plant inspection of the bathrooms was conducted with the facility director on July 16, 2012 at approximately 9:40 AM. The facility has four bathrooms. There are not any windows located in these bathrooms. The exhaust fans were not operable in any of the bathrooms. The facility director confirmed the findings.
On July 20, 2012 at approximately 2:15 PM, the facility director reported that the building maintenance department confirmed the bathroom fans were no longer operable.
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Plan of Correction
Under the direction of the Clinical Administrator, the Exhaust fans in all bathrooms were repaired on 7/23/12 by Jim, Facilities Maintenance at Oxford Development and continue to work properly as of this date, 8/23/12. Ventilation of the bathrooms by exhaust fan will be monitored on a monthly basis by the Program Director via tissue test. |
711.81(b)(6) LICENSURE Psychosocial Evaluation
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the client in three of four partial hospitalization client records.
The findings include:
Twenty-four client records were reviewed on July 16 - 18, 2012. Seven client records pertained to the partial hospitalization activity. Five partial hospitalization client records were reviewed for documentation of a psychosocial evaluation. The psychosocial evaluations failed to include a clinical assessment of the client in client records # 1, 2 and 6.
Client # 1 was admitted into treatment on June 25, 2012. The psychosocial evaluation was completed on June 26, 2012. The psychosocial evaluation included client reported historical information and was not a clinical assessment of the client.
Client # 2 was admitted into treatment on June 11, 2012. The psychosocial evaluation was completed on June 7, 2012. The psychosocial evaluation included client reported historical information and was not a clinical assessment of the client.
Client # 6 was admitted into treatment on May 17, 2012. The psychosocial evaluation was completed on May 10, 2012. The psychosocial evaluation included client reported historical information and was not a clinical assessment of the client.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Under the direction of the Clinical Administrator or her designee, assessment summaries for partial hospitalization patients will contain clinical impressions provided by the assessor. Staff will receive training on the required elements of assessment summaries and utilizing clinical impression language by 9/15/12 during treatment team. Clinical supervisors will conduct a monthly audit of a minimum of 3 assessment summaries per week and reviewed at weekly at team meetings beginning the month of October 2012 and ending the month of January 2013 to ensure that assessment summaries are documented utilizing clinical language. Results of audits will be shared with Program Administration.. |
711.15(b) LICENSURE Subchapter B.Approval Procedures.Right to ent
711.15. Right to enter and inspect.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
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Observations
Based on the review of administrative documentation, the facility failed to allow full and free access to the records of the facility.
The findings include:
The Staffing Requirements Facility Summary Report was reviewed on July 30, 2012. The Chief Executive Officer of the program had been listed as the project director at Project facilities inspected the prior week. The personnel record for this person was not available for review at the previous inspections and was to be made available for review on July 30, 2012. At the time of the July 30, 2012 inspection, the Project Director's personnel record was not made available.
The reason provided for the refusal to grant access to this information was that the Chief Executive Officer was no longer listed as the project director. The Chief Executive Officer was not listed as the project director on the staffing form reviewed on July 30, 2012. The person identified on this staffing form as the project director had been reviewed only as the facility director at the previously inspected facilities. As a result, the job descriptions for both the Chief Executive Officer and the currently listed project director were requested. The CEO remained an employee of the Project. As of July 31, 2012, neither of the job descriptions had been made available for review.
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Plan of Correction
Under the direction of the Clinical Administrator or her designee, the facility will give DDAP full and free access to the relevant records of the facility and its clients. Effective 8/1/12, access to all relevant records will be provided upon request during the onsite licensing inspections by the Clinical Administrator or her designee for all future inspections. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the client in four of nine outpatient client records.
The findings include:
Twenty-four client records were reviewed on July 16 - 18, 2012. Seventeen client records pertained to the outpatient activity. Nine outpatient client records were reviewed for documentation of a psychosocial evaluation. The psychosocial evaluations failed to include a clinical assessment of the client in client records # 8, 18, 20 and 23.
Client # 8 was admitted into treatment on June 5, 2012. The psychosocial evaluation was completed on May 23, 2012. The psychosocial evaluation included client reported historical information and was not a clinical assessment of the client.
Client # 18 was admitted into treatment on June 27, 2012. The psychosocial evaluation was completed on June 27, 2012. The psychosocial evaluation included client reported historical information and was not a clinical assessment of the client.
Client # 20 was admitted into treatment on May 22, 2012. The psychosocial evaluation was completed on January 25, 2012. The psychosocial evaluation included client reported historical information and was not a clinical assessment of the client.
Client # 23 was admitted into treatment on October 18, 2011. The psychosocial evaluation was completed on October 18, 2011. The psychosocial evaluation included client reported historical information and was not a clinical assessment of the client.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Under the direction of the Clinical Administrator or her designee, ssessment summaries for out patients will contain clinical impressions provided by the assessors. Staff will be trained on the use of clinical language in assessment summaries by 9/1/12. Clinical supervisors will conduct an audit of a minimum 3 assessment summaries at weekly team meetings with clinicians beginning the month of September 2012 and ending the month of December 2012 to ensure that psychosocial evaluations include a clinical assessment of the client. Results will be shared monthly with Program Administration. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in one of two outpatient client records.
The findings include:
Twenty-four client records were reviewed on July 16 - 18, 2012. Seventeen client records pertained to outpatient client records. Two outpatient clients records required documentation of an aftercare plan. The facility failed to document an aftercare plan in client record # 21.
Client # 21 was admitted into treatment on July 28, 2011 and was successfully discharged on June 28, 2012. There was no documentation of an aftercare plan in client record # 21 as of July 18, 2012.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Under the direction of the Clinical Administrator or her designee, aftercare plans will be completed on all patients. Staff will be re-trained on the requirement of Aftercare plans by 10/1/12. The clinical supervisors will randomly audit a minimum of 3 patient charts per month to monitor compliance with completion of aftercare plans. Audits will begin the month of October 2012 and will end the month of January 2013. Results of audits will be shared with clinical staff in supervision meetings and with Program Administration. |