INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 06, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Treatment 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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704.12(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 the 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. Employee # 10 has been in the counselor position since November 30, 2020. Employee #10 was reported to have 37.5 hours per week devoted to their 37 clients on their caseload.Employee #12 has been in the counselor position since November 08, 2021. Employee #12 was reported to have 37.5 hours per week devoted to their 37 clients on their caseload.Employee #13 has been in the counselor position since January 31, 2022. Employee #13 was reported to have 37.5 hours per week devoted to their 45 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 for Employee #10 is as follows: 37.5/37.5 = 1(FTE); 37/1 = 37, which equals to a client/counselor ratio of 37:1.The FTE counselor ' s caseload calculation for Employee #12 is as follows: 37.5/37.5 = 1(FTE); 37/1 = 37, which equals to a client/counselor ratio of 37:1.The FTE counselor ' s caseload calculation for Employee #13 is as follows: 37.5/37.5 = 1(FTE); 45/1 = 45, which equals to a client/counselor ratio of 45:1.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
-Caseloads will continue to be reviewed weekly in our QA Meeting to monitor admits and discharges more closely to stay between the client/counselor ratio
-Discharges and relapses will be reviewed weekly in supervision and type and frequency of treatment will be altered upon patient progress or set backs.
-Clinical staff will hand in their active caseload numbers weekly to monitor more closely.
-This process will be monitored by the Clinical Director and Quality Management officer
-Staff training for license POC will be held 12/19/24 to discuss these changes. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of outpatient client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in six of seven records reviewed.Client #1 was admitted on April 30, 2024, and was still active at time of the inspection. The individual treatment and rehabilitation plan was completed on May 9, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.Client #3 was admitted on January 2, 2024, and discharged October 18, 2024. The individual treatment and rehabilitation plan was completed February 12, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services. Client #4 was admitted on February 16, 2024, and discharged June 26, 2024. The individual treatment and rehabilitation plan was completed on March 7, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.Client #5 was admitted on April 10, 2024, and was still active at time of inspection. The individual treatment and rehabilitation plan was completed on May 1, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services. Client #6 was admitted on January 8, 2024, and discharged on June 28, 2024. The individual treatment and rehabilitation plan was completed on January 30, 2024; however, the plan did not include documentation. Client #7 was admitted on March 21, 2024, and still active at time of inspection. The individual treatment and rehabilitation plan was completed on June 10, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
-Policy Manual change was added today to state: "Frequency of both group and individual counseling services varies based on presenting needs of patient. If type/frequency changes vs. what is noted in the master treatment plan this will be noted in the next treatment plan update".
-All staff will be re-trained about the importance of documenting and updating the treatment progress through progress notes, general contact notes and updates to reflect the change in type and frequency if necessary. This training will take place on 12/19/24.
-The process for this change will be monitored by Clinical Director through case file reviews and audits completed randomly in house.
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