INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 13-14, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northern Tier Counseling 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 and a plan of correction is due on November 7, 2009.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of administrative documentation the facility failed to provide documentation of the required monthly meetings.
The findings include:
There was no documentation available during the inspection to demonstrate monthly supervisory meetings with the clinical supervisor and the project/facility director.
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Plan of Correction
For future reference, any new employee in the Program Manager position will receive documented monthly supervision from the Clinical Director for a minimum of their first 6 months of employment, and the documentation will also include justification for decreasing the frequency of supervisory meetings thereafter. This policy will be added to the Policy and Procedure Manual and will be followed accordingly. The Clinical Director will complete the supervision nor=tes monthly as required. NTC's Compliance Committee will also complete internal audits periodically to ensure the appropriate supervision documentation is completed in a timely manner. |
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 client census lists, the self report staffing form completed by the clinical supervisor on October 13, 2009 and interviews with the project director/facility director and the clinical supervisor on October 13, 2009, the facility failed to maintain caseloads at the required 35:1 maximum.
The findings include:
One counselor and one counselor assistant had documented client counselor ratios exceeding the maximum allowable 35:1 ratio. Employee #2 had a ratio of 37:1; employee # 3 had a ratio 38:1.
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Plan of Correction
1. D&A Counselor's caseload will be reviewed weekly by the Program Manager to ensure client ratio compliance; if maximum caseload is reached, referrals will be diverted to other providers.
2. NTC has allocated several D&A clients (maximum of 5) to several qualified staff members within the agency to lower the staff to client ratio, and this will continue until the Primary Counselor position is filled.
Both corrective action plans will be monitored by the Program Manager, and overseen for compliance by NTC's internal Compliace Committee.
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