Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure the FTE counselor caseload for counseling in outpatient programs did not exceed 35 active clients in one of four applicable personnel records reviewed.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee # 3 was hired as a counselor on June 2, 2021 and was still employed. The employee's ratio calculation was as follows: 40/40 = 1(FTE); 37/1=37, which equals to a client/counselor FTE ratio of 37:1.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director has adjusted employee 3 caseload to reflect the correct amount of clients based on the correct ratios. The facility director will ensure that all client caseloads follow the same protocol by following the formula provided in order to prevent incorrect assignment. The facility director will check weekly on admissions, discharges and assignments to keep correct carloads at all times. |
Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in five of six applicable client records reviewed.
Client #1 was admitted December 12, 2023 and was active at the time of inspection. The comprehensive treatment plan was completed on December 14, 2023 and the first update was due no later than February 14, 2024; however, the update was completed on February 23, 2024.
Client #2 was admitted May 15, 2023 and was active at the time of inspection. A treatment plan update was completed on October 9, 2023 and the next update was due no later than December 9, 2023; however, the update was completed on January 10, 2024.
Client #3 was admitted September 25, 2023 and was active at the time of inspection. The comprehensive treatment plan was completed on September 25, 2023 and the first update was due no later than November 25, 2023; however, the update was completed on January 30, 2024.
Client #6 was admitted September 12, 2023 and was discharged October 27, 2023. A treatment plan update was completed on September 12, 2023 and the next update was due no later than November 12, 2023; however, the update was not completed prior to discharge.
Client #7 was admitted April 5, 2023 and was discharged November 20, 2023. A treatment plan update was completed on September 1, 2023 and the next update was due no later than November 1, 2023; however, the update was not completed prior to discharge.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor along with the facility director will hold an in-service training with all clinical staff to review treatment/recovery plans timeframes including PTP within 15 days of admission, CTP within 30 days of admission, and updates every 60 days after. The in-service training will also review the importance of completing and documenting each plan with the client and highlight review and completion dates.
The facility director will also complete weekly reviews of documentation that must be filed along with compliance reports to ensure clinical documents completions and that documents are available for reviews timely. |