INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the November 22 - 23, 2010 licensure renewal inspection.
The follow-up inspection was conducted on June 17, 2011 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the onsite follow-up inspection, WES Corporation 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 a review of three counselors active caseloads, and a conversation with the facility director and counselor # 3, the facility failed to ensure that staff to client caseloads remained at or under 35:1.
The findings included:
On June 17, 2011 an unannounced follow-up inspection was conducted.
The program support specialist provided the surveyor with three active client list.
The active client list was for the facilities three full-time counselors.
The facility's standard work week, as reported by the facility is 37.5 hours per week.
Based on the number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week, 37.5, and the total number of clients assigned to the following employee on June 17, 2011, employees # 3 was assigned a caseload that exceeded the maximum caseload of 35:1.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to clinical treatment by the facility's standard workweek.
The number or hours per week devoted by employee # 3 to client treatment, as reported by the facility was 37.5 hours per week.
The facility reported on the active client list that employee # 3 had 48 active clients on June 17, 2011.
Employee # 3 (37.5/37.5 = 1 FTE48 clients/1 FTE = 48:1 caseload)
The facility director and counselor # 3 confirmed that the caseload exceeded 35:1.
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Plan of Correction
The facility will correct the deficiency and ensure that caseloads do not exceed 35;1, the facility will be in compliance by 8/31/11.
WES Corporation will assign new intakes to staff based on current caseloads; the facility director will assume cases or hire new clinicians accordingly.
The facility director with the assitance of the Vice President of Operations will ensure that the defieciency does not recur and case loads will not exceed 35:1 ratio through bi-weekly census reports, hiring qualified clinicains, and/or not admitting new clients until there is a sufficient number of staff to maintain caseloads at 35:1.Caseloads with active clients currently are 35:1.
This plan of correction will be implemented by 8/31/11. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a physical plant inspection, observation, and a conversation with the Facility Director, the facility failed to maintain confidentiality of client identity and records.
The findings include:
A physical plant inspection was conducted on June 17, 2011 at approximately 3 PM.
A client sign in sheet was observed in an office.
The sign in sheet included a list of client first and last names, the date, number of tokens received, and the name of the client's counselor.
The Facility Director confirmed that the sign in sheet included client first and last names.
This is a repeat deficiency, the facility was cited during the November 23, 2010 inspection for failing to maintain confidentiality of client identity.
In response to the citation issued on June 4, 2010 the facility's plan of correction submitted on 1/6/2011 and approved on 1/12/2011, stated the following:
"The client sign in sheet used to monitor the distribution of tokens has been revised and the clients will now sign first name and last initial to insure confidentiality. All clients have been informed of the change in procedure. The program director or designee will monitor for compliance."
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Plan of Correction
Substance Abuse PIR will no longer have access to the token distribution Log.
All Program Staff have been provided Token Distribution Logs on which to document the distribution of tokens to program PIR.
Program Staff will be responsible for documenting the date, the first name and last initial of the PIR along with the number of tokens provided to PIR and initial that they provided the tokens.
Program staff will maintain their individual token distribution sheets in a folder and provide the Token Distribution Log to the Program Director weekly.
The Program Director will file the Token Distribution Log in the Token Binder.
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709.92(a) 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:
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Observations
Based on a review of client records, a review of the facility's policies and procedures manual, and a conversation with the director of quality management, the facility failed to document an individual treatment plan in accordance with facility policy in seven of seven client records.
The findings include:
The facilities policy titled "Initial Evaluations" states:
All new consumers must receive an intake evaluation, a comprehensive bio-psychosocial assessment and a psychiatric evaluation, in that order, when applicable.
The facilities policy titled "Initial and Updated Treatment Plans" states:
A comprehensive individualized treatment plan shall:
II. Be based upon a diagnostic evaluation which includes examination of the medical, psychological, social, cultural, behavioral, familial, educational, vocational, and developmental aspects of the client's situation.
On June 17, 2011 seven client records were reviewed for documentation of a comprehensive individualized treatment plan.
The facility failed to document a comprehensive individualized treatment plan, in accordance with facility policy, in client records # 1, 2, 3, 4, 5, 6, and 7.
Client # 1 was admitted to the program on 3/23/11, and at the time of review was an active client. Per facility policy, a comprehensive treatment plan is based upon a comprehensive bio-psychosocial assessment.
The facility documented the comprehensive treatment plan on 3/23/11; however, the bio-psychosocial assessment was documented on 3/29/11.
Thus the comprehensive treatment plan for client # 1 was not based on the comprehensive bio-psychosocial assessment.
Client # 2 was admitted to the program on 5/19/11, and at the time of review was an active client. Per facility policy, a comprehensive treatment plan is based upon a comprehensive bio-psychosocial assessment.
The facility documented the comprehensive treatment plan on 5/19/11; however, the bio-psychosocial assessment was not documented at the time of review on 6/17/11. Thus the comprehensive treatment plan for client # 2 was not based on the comprehensive bio-psychosocial assessment.
Client # 3 was admitted to the program on 3/8/11 and discharged on 4/25/11. Per facility policy, a comprehensive treatment plan is based upon a comprehensive bio-psychosocial assessment.
The facility documented the comprehensive treatment plan on 3/8/11; however, the bio-psychosocial assessment was documented on 3/16/11.
Thus the comprehensive treatment plan for client # 3 was not based on the comprehensive bio-psychosocial assessment.
Client # 4 was admitted to the program on 3/23/11 and discharged on 5/11/11. Per facility policy, a comprehensive treatment plan is based upon a comprehensive bio-psychosocial assessment.
The facility documented the comprehensive treatment plan on 3/23/11; however, the bio-psychosocial assessment was not documented at the time of review on 6/17/11. Thus the comprehensive treatment plan for client # 4 was not based on the comprehensive bio-psychosocial assessment.
Client # 5 was admitted to the program on 4/21/11, and at the time of review was an active client. Per facility policy, a comprehensive treatment plan is based upon a comprehensive bio-psychosocial assessment.
The facility documented the comprehensive treatment plan on 4/13/11; however, the bio-psychosocial assessment was documented on 4/25/11.
Thus the comprehensive treatment plan for client # 5 was not based on the comprehensive bio-psychosocial assessment.
Client # 6 was admitted to the program on 5/19/11, and at the time of review was an active client. Per facility policy, a comprehensive treatment plan is based upon a comprehensive bio-psychosocial assessment.
The facility documented the comprehensive treatment plan on 5/19/11; however, the bio-psychosocial assessment was documented on 5/27/11.
Thus the comprehensive treatment plan for client # 6 was not based on the comprehensive bio-psychosocial assessment.
Client # 7 was admitted to the program on 5/11/11, and at the time of review was an active client. Per facility policy, a comprehensive treatment plan is based upon a comprehensive bio-psychosocial assessment.
The facility documented the comprehensive treatment plan on 5/11/11; however, the bio-psychosocial assessment was documented on 5/19/11.
Thus the comprehensive treatment plan for client # 7 was not based on the comprehensive bio-psychosocial assessment.
The director of quality management confirmed the facilities policy and stated that a comprehensive bio-psychosocial assessment is to be documented before the comprehensive treatment plan.
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Plan of Correction
The facility will correct the deficiency and ensure that comprehensive individualized treatment plans are documented and in compliance according to the board policy by 9/30/11.
WES Corporation will follow the board approved policy regarding Intial Evaluations and Comprehensive Treatment Plan and Updated Treatment Plans.
Staff/Clinicians will be trained according to the approved policy & regulations during a topic related inservice by 9/30/11.
The facility director with the assitance of the Vice President of Operations and the Director of Quality Management will ensure all staff are adhering to the policy and procedure and are in compliance via monthly chart audits, staff supervision and topic related trainings. This plan of correction will be implemented and effective as of 9/30/11. |