INITIAL COMMENTS
|
This report is a result of a complaint investigation conducted on December 16, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Davis Archway House were unsubstantiated, but additional areas of non-compliance were found during the course of the complaint investigation. A plan of correction must be submitted by January 10, 2011.
|
Plan of Correction
|
704.12(a)(3)(i) LICENSURE NonHosp Rehab
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.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report form (pages 3 and 5), completed by the project/facility director on December 16, 2010, and a discussion with the project/facility director, the facility failed to ensure that the staff to client ratios remained at or below 8:1.The findings include: On December 16, 2010, pages 3 and 5 of the Staffing Requirements Facility Summary Report form completed by the facility was reviewed . The form listed the project director/facility director/clinical supervisor, three counselors and one counselor assistant as the clinical staff compliment, however, one of the three counselors is currently on medical leave, and the counselor assistant is currently in the direct observation supervision period and neither one could have hours counted toward the clinical staff compliment regarding the equation for determining client to staff ratios.The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.Based the total 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 (40), and the total number of current clients as of December 16, 2010, the facility's client to counselor ratios exceeded 8:1. The actual client ratio 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 the clients' treatment by the facility's standard work week. The number of hours per week for the two counselors and the project director/facility director/clinical supervisor was 110 hours. 110 divided by the facility work week of 40 hours equals 2.75 FTE. The number of current clients is 27 divided by the 2.75 FTE is 9.8. This results in a ratio of 10:1 which exceeds the maximum of 8:1.
|
Plan of Correction
The Facility Director recalculated the correct FTE ratio by excluding the counselor assistant hours during the direct observation period. The remaining clinical hours were derived from the remaining staff of the clinical team. The number of clients residing in the facility has been adjusted to meet the standards and the current ratio is 7.70:1. This has been completed as of December 27, 2010. The Facility Director will continue to monitor the FTE calculations to ensure continued compliance. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
Based on a review of facility policy and procedure, the client handbook and a discussion with the project/facility director, the facility failed to provide a policy and procedure for drug screen urinalysis testing and results. The findings include: The facility utilizes drug screen testing with clients, but does not have policy and/or procedures regarding the process.
|
Plan of Correction
The Facility Director formulated a step by step written policy for drug screen testing of clients and will review this information with all staff at the staff meeting on December 30, 2010. At the meeting all staff will be informed of the correct procedure for drug screening of clients and given opportunity to address questions/concerns. The written policy will be made part of the client handbook and will also be included in the employee handbook. |