INITIAL COMMENTS
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This report is a result of an onsite capacity increase inspection conducted on August 4-5, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northern Tier Counseling, 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 September 1, 2010.
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct unannounced drills at least once a month.
The findings include:
Based on the review of the Fire Drill Log and and interview with the Human Resource Manager on August 4, 2010, the facility failed to conduct unannounced drills at least once a month. A review of facility documentation revealed the facility conducted fire drills in October 1, 2009 and May 6, 2010; no additional fire drills were documented.
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Plan of Correction
A new agency policy was drafted mandating each site o conduct a Fire Drill at least once monthly. This policy will by reviewed for compliance by the agency's Compliance Committee, which meets quarterly. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the fire drill record log, the facility failed to document monthly fire drills.
The findings include:
The fire drill record log was reviewed on August 4, 2010. The log was reviewed from June 2009-June 2010. Two of those twelve months were documented that a fire drill was conducted. October 1, 2009 and May 6, 2010 were the two months that were document fire drills. This was confirmed with the Human Resource manager on August 4, 2010.
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Plan of Correction
A new agency policy was drafted and implemented mandating each site to conduct a Fire Drill at least once monthly. This policy will by reviewed for compliance by the agency's Compliance Committee, which meets quarterly. |
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 and an interview with the facility Human Resource Manager, the facility failed to ensure that staff to client ratios remained at or under 35:1.
The findings included:
Based on the number of hours the employee worked at this facility, and the number of clients on the counselors' caseload(16), the counselor exceeded the caseload of 35:1. The counselors/client ratio was 38/1. An interview with the Human Resource Manager on August 4, 2010 at 10:30 AM confirmed that the facility was aware of this problem.
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Plan of Correction
1. D&A Counselor's caseload will be reviewed weekly by the Program Manager to ensure client ratio compliance; if maximum caseload is reached, referrals will be diverted to other providers.
2. NTC will continue to allocate D&A clients (maximum of 5) to other qualified staff members within the agency to ensure compliance with the staff to client ratio of 35:1.
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