INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8-10, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Deerfield Centers for Addiction Treatment 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)(1)(i) LICENSURE Client/couns ratios
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.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
The Staffing Requirements Facility Summary Report was completed and reviewed on April 11, 2019. Employee # 2 was hired as on July 10, 2000 and promoted to current position on June 15, 2015. Employee #2 was reported to have 8 hours per week devoted to their 10 clients on their caseload at the Tionesta location.
The FTE counselor ' s caseload calculation is as follows: 8/35= . 2286 (FTE); 10/.2286= 43.7446, which equals to a client/counselor ratio of 44:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director shall ensure the caseload of each clinician is no more than 35 across main and all satellite sites. This will be accomplished through tracking measures and/or weekly team meetings. On 3/14/19 Facility Director did relieve clinician #2 of three clients in the Tionesta location. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
During an onsite inspection conducted April 8-10, 2019, the facility failed to provide documentation of a termination letter for client # 9.
Client # 9 was admitted on June 20, 2017 and was administratively discharged on November 5, 2018. There was no documentation in the client record that the client received a termination letter.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director shall ensure those clients which are administratively discharged by any Deerfield staff are alerted in person of decision to discharge and will have right to file an appeal. If client is unwilling to attend discussion in person then client will be notified via postal mail of decision made with right to appeal. Signed Termination Letter will be filed under 'Correspondence' portion of chart. If client is unwilling to sign letter staff will acknowledge letter was discussed with client and sign "client refusal" and date letter in which discussion took place. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of outpatient client records, on April 9-10, 2019, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in 4 of 9 charts reviewed.
Client # 1 was admitted on April 16, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan, dated April 30, 2018, indicated one individual session weekly. The chart's record of service and progress notes indicated that the client had not received any sessions after March 21, 2019.
Client # 3 was admitted on July 26, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan, dated August 14, 2018, indicated one individual session weekly. The chart's record of service and progress notes indicated the client was being seen on a bi-weekly basis and the treatment plan was not updated to document this change.
Client # 5 was admitted on January 17, 2019 and was still an active client at the time of the inspection. The comprehensive treatment plan, dated February 7, 2019, indicated one individual session weekly. The chart's record of service and progress notes indicated the client did not receive services the weeks of February 14 through March 21.
Client # 6 was admitted on July 12, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan, dated July 26, 2018, indicated one individual session weekly. The chart's record of service and progress notes indicated the client was being seen on a bi-weekly basis and the treatment plan was not updated to document this change.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director shall add "Type" (IOP or Outpatient) and "Frequency" ( 2x per week, weekly, Bi-weekly, Monthly) to Treatment Plan Update and Case Consult template to properly reflect and document mode and frequency of clinical services.
Clinicians will continue to be encouraged to record when attendance letters are sent under the 'comment' section of Outpatient Tracking Sheet. Attendance letters will continue to be filed under Correspondence section of client file. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on review of 3 discharge records conducted on April 9-10, 2019, the facility failed to provide documentation of follow-ups in 2 client records.
Client # 7 was admitted on June 20, 2018 and unsuccessfully discharged on December 26, 2018. The facility ' s Policy and Procedure says that a follow-up will occur after one month of discharge only. There was no documentation that a follow up was conducted.
Client # 8 was admitted on May 17, 2018 and successfully discharged on July 12, 2018. The facility ' s Policy and Procedure says that a follow-up will occur at one month and six months. There was no documentation that a follow up was conducted.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility shall combine Warren Aftercare Tracking Form, Tionesta Rolling Tracking Form, and Marienville Rolling Tracking form into one DCAT Rolling Master Aftercare Tracking Form. Facility shall add "successful/unsuccessful" column after name column in order to ensure tracking form procedures are handled correctly for both successful ( 1 & 6 month follow ups) and unsuccessful 1 month follow up) clients. |