INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on December 10, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Adams Hanover Counseling Services, Inc.(Shrewsberry) 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 the staffing requirements facility summary report form completed by the facility on January 10, 2012 and a discussion with the two counselors on staff on January 10, 2012, the facility failed to ensure that staff to client ratios remained at or under 35:1.
The findings included:
Two counselors caseloads were reviewed on January 10, 2012. Based on the number of hours the employee worked at this facility, and the number of clients on the counselors' caseload, one counselor exceeded the caseload of 35:1. Counselor # 1 had a documented caseload that was less than 35:1. Counselor # 2 had a caseload of 38:1, which exceeds the maximum of 35:1.
A discussion with staff on January 10, 2012, confirmed these findings.
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Plan of Correction
The Clinical Supervisor has reviewed the findings with both counselors. This discussion was initiated on 10 Jan 2012 discussing the requirements of client ratios of at or under 35:1. The Clinical Supervisor is reviewing the number of cases documented on each counselors' caseload weekly to make sure that we are and will remain in compliance. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and a discussion with the clinical supervisor, the facility failed to adhere to the authorized maximum client capacity of 28 clients.
The findings include:
The Staffing Requirements Facility Summary Report was reviewed on January 10, 2012. Based on the information the facility provided, the facility exceeded its authorized maximum capacity of 28 clients.
The number of clients recorded on the Staffing Requirements Facility Summary Report was 36 clients. During a discussion with the two counselors, the number of active clients was currently 36. She also acknowledged that she was aware the facility was over its authorized maximum capacity of 28 clients.
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Plan of Correction
The Executive Director and the Project Director are in the process of drafting a letter requesting that our maxium client capacity be raised. This letter will be faxed to your office by close of business on 2/15/2012.
The Clinical Supervisor will continue to document the number of clients scheduled daily each morning to ensure that we are not over our the maxium capacity. Both counselors will be notified if we go over our maximum capacity on any given day to take action to bring us back into compliance. |