INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 1, an abbreviated off-site inspection, conducted on June 22, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.Based on the findings of Part 1, an abbreviated off-site inspection, Aldie Counseling Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiency was 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 Requirement Facility Summary Report, the facility failed to ensure that all outpatient counselors did not exceed the 35 to 1 counselor to client ratio in five of thirteen applicable counselors. 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's ratio calculation was as follows: 16/40=.4 (FTE); 8/.4 =37.5, which equals to a client/counselor ratio of 38:1.Employee #5's ratio calculation was as follows: 40/40=1 (FTE); 37/1 =37, which equals to a client/counselor ratio of 37:1.Employee #7's ratio calculation was as follows: 20/40=.5 (FTE); 20/.5 =40, which equals to a client/counselor ratio of 40:1.Employee #10's ratio calculation was as follows: 40/40=1 (FTE); 36/1 =36, which equals to a client/counselor ratio of 36:1.Employee #11's ratio calculation was as follows: 40/40=1 (FTE); 36/1 =36, which equals to a client/counselor ratio of 36:1.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to correct the deficiency it will be necessary to hire a new counselor. Aldie is in the process of hiring a counselor for the Langhorne facility. Interviews will be conducted by the Clinical Director and Clinical Supervisor during the month of July. It is anticipated that the vacancy will be filled by August 15, 2020. To ensure continued compliance the Clinical Director will monitor (on a not less than monthly basis) an internal staffing spreadsheet and adjust counselor caseloads accordingly so that the ratio does not exceed 35 to 1. In the event of a staff vacancy, recruitment of replacement staff will begin as soon as the vacancy is known and all efforts will be made to fill open position within 60 days. |