INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 3, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling and Psychiatric 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of seven personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that two employees received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a Counselor on June 3, 2019 and was due to have the communicable disease trainings no later than June 3, 2020. Documentation within the personnel record indicated employee #3 did not receive the training until August 28, 2020.
Employee #6 was hired as a counselor on June 3, 2019 and was due to have communicable disease trainings no later than June 3, 2020. Documentation within the personnel record indicate that employee #6 did not receive HIV/AIDS training until December 8-9, 2020 and TB/STD training until December 16, 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Employee #3 was registered for HIV/AIDS trainings on 4/9/20 & 6/23/20, both trainings were canceled.
Employee #6 was registered for HIV/AIDS trainings on 4/9/20 & 6/23/20, both trainings were canceled.
Due to the pandemic, many PCS staff had difficulty completing the required trainings. The Director of Outpatient Services is currently working with the PCS Training Department to develop curriculum to be approved by DDAP so that in-house communicable disease trainings can be offered to PCS staff to ensure completion within the regulatory timeframes.
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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 on March 3, 2021, one counselor caseload exceeded the counselor/client ratio.
Employee #7 was hired as a counselor on October 8, 2018 and was still acting in that position. Employee #7 was reported to have 9 hours per week devoted to their 10 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 35. 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 is as follows: 9/35 = .25714(FTE); 10/.25714 = 38.889, which equals to a client/counselor ratio of 39:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Improvement made an error in completing the Facility Summary Report. It should have read that Employee #7 devotes 9 hours per week for 8 clients. Employee #7 did not have 10 clients. The Director of Quality Improvement will ensure that future Facility Summary Reports are reviewed prior to submission to assist in reducing clerical errors. |