INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 7, 2008 - July 10, 2008, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Progressive Medical Specialists, Inc. 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 August 15, 2008.
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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 review of the Staffing Requirements Facility Summary Report on July 10, 2008, the facility failed to ensure that client caseloads were at or less than 35:1. The overall caseload for this facility was at 47:1. An open caseload of 52 clients was reported on the Staffing Requirements Facility Summary Report.
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Plan of Correction
Two open counselor postions were filled, one counselor will begin on August 4, 2008 and the counselor will begin on August 11, 2008.
These two filled positons will put us back into compliance withthe 35:1 ratios |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on review of 6 client records on July 9, 2008 through July 10, 2008, four client records were determined to require individualized treatment plans. The facility failed to document goals and objectives that were consistent with the counselor's assessments documented on the psychosocial evaluation, nor were they consistent with the problem list developed by the counselor. The treatment plans were not individualized in four of four client records where required.
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Plan of Correction
This continues to be an area that counselors work on daily.
The clinical supervisor from the Washington county office has transferred to the Pgh location, she will begin to work with counselors in treatment planning.
The clinical supervisor will meet with each counselor weekly for the next four weeks to review each treatment plan that was completed by the counselor that week. The clinical chart will be provided and the clinical supervisor will review the problem list with the treatment plan to ensure that problems are being addressed and that each goal is specific to the individual client.
We continue to seek out trainings for clinical treatment planning on-line and in our area. If any outside trainings found the director will send staff..
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