INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16, 2014 - September 17, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Service and Children ' s Aid Society 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel and training records, the facility failed to provide documentation of HIV/AIDS and TB/STD training in one of three personnel records reviewed. Additionally, the facility failed to ensure that a staff member completed TB/STD training within the first year of employment in one of three personnel records reviewed The findings include:Three personnel records which required documentation of mandatory communicable disease training were reviewed on September 9, 2014. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee # 3. Additionally, the facility failed to ensure that TB/STD training was completed within the first year of employment for employee # 5. Employee # 4 was hired 9/9/2008 as a transportation driver. This employee was required to obtain six hours of HIV/AIDS and 4 hours of TB/STD training by 9/9/2010. Employee # 4 failed to obtain the training as of the date of the inspection.Employee # 5 was hired 2/4/2013 as a counselor. This employee was required to obtain 4 hours of TB/STD training by 2/4/2014. Employee # 5 completed the TB/STD training on 5/14/2014. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Documentation of attendance and completion at HIV/AIDS and TB/STD trainings for Employee #3 were submitted and reviewed by Justin Trupp, Licensing Specialist on Wednesday, September 16, 2014.
Employee# 4 was informed of the need to complete the required 6hrs of HIV/AIDS and 4hrs of TB training on Friday September 19, 2014. The trainings will be scheduled for employee #4 and will completed by December 31, 2014.
Employee #5 did not complete the TB training within the required first year of employment. Employee #3 completed her TB training 3 months after required year of service. The Facility Director will ensure all new employees are scheduled and attends the required trainings within the first year by scheduling the trainings in house and/or via DDAP or other agencies. Each new employee will complete upon hire a training plan that is consistent with requirement of completion. |
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 on 9/4/2014 and an interview with the facility director, the facility failed to ensure that staff caseloads remained at or under 35:1.The findings include: The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on 9/9/2014. Based on the total number of hours per week that that employee #2 devoted to clients and the standard work week of 35 hours, employee # 2 exceeded the allowable maximum 35:1 caseload.The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by the standard work week of 35 hours. The number of hours per week devoted by Employee # 2 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 6 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 2 had 9 active clients on 9/4/2014.Employee # 2 (6/35 = .1714 FTE 9 clients/.1714 FTE = 53:1 caseload)These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and/or Clinical Supervisor will monitor employee #2 and all other clinical staffs caseloads on a daily basis that they all are in compliance with the allowable maximum35:1 caseload. Employee # 2 was informed of her allowable caseload as dictated by the FTE Formula. Her caseload was below the allowable 35:1 on date of site inspection and will remain there. This Formula was explained to all clinical and appropriate admin staff from September 11th thru Monday, September 22,2014. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document an annual performance evaluation in one of five applicable personnel records reviewed.The findings include:Five personnel records requiring documentation of an annual performance evaluation were reviewed on 9/9/2014. The facility failed to document an annual performance evaluation in personnel record # 1. Employee # 1 was hired as the project director on 1/22/2008. Employee # 1 ' s last annual performance evaluation was completed on 7/25/2012. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director (Employee #1) will have her Employee performance evaluation completed and reviewed by the governing board's personnel committee by 10/31/14. In the future, the Facility Director will ensure that all Employee performance evaluations are done on a yearly basis. Effective January 2015, as a standard procedure, all agency performance evaluations will be completed by February 28th yearly. |
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 the review of client records, the project failed to ensure that counseling services were provided according to the individual treatment plan in seven of ten client records reviewed. The findings include:Ten client records were reviewed on 9/16/2014 for the provision of providing counseling services in accordance with treatment plans. The project failed to ensure that clients received counseling services according to the client's individual treatment plan in client records # 2, 3, 4, 5, 7, 9 and 10.Client record # 2 contained a treatment plan dated 7/11/2014 that identified the counseling services to be provided as an individual session one time per week. The record did not contain documentation of any individual sessions during the week of 8/11/2014 - 8/15/2014. Client record # 3 contained a treatment plan dated 11/25/2013 that identified the counseling services to be provided as an individual session one time per week. The record did not contain documentation of any individual sessions during the weeks of 11/25/2013 - 11/29/2013 and 12/9/2013 - 12/13/2013.Client record # 4 contained a treatment plan dated 10/11/2013 that identified the counseling services to be provided as an individual session one time per week. The record did not contain documentation of any individual sessions during the weeks of 11/18/2013 - 11/22/2013, 11/25/2013 - 11/29/2013, 12/16/2013 - 12/20/2013, 12/23/2013 - 12/27/2013 and 12/30/2013 - 1/3/2014.Client record # 5 contained a treatment plan dated 11/22/2013 that identified the counseling services to be provided as an individual session one time per week. The record did not contain documentation of any individual sessions during the weeks of 11/18/2013 - 11/22/2013, 12/9/2013 - 12/13/2013 and 12/23/2013 - 12/27/2013.Client record # 7 contained a treatment plan dated 11/26/2013 that identified the counseling services to be provided as an individual session one time per week. The record did not contain documentation of any individual sessions during the weeks of 11/25/2013 - 11/29/2013 and 12/30/2013 - 1/3/2014.Client record # 9 contained a treatment plan dated 7/28/2014 that identified the counseling services to be provided as an individual session one time per week. The record did not contain documentation of any individual sessions during the weeks of 7/28/2014 - 8/1/2014, 8/18/2014 - 8/22/2014 and 9/1/2014 - 9/5/2014. Client record # 10 contained a treatment plan dated 8/8/2014 that identified the counseling services to be provided as an individual session one time per week. The record did not contain documentation of any individual sessions during the week of 8/11/2014 - 8/15/2014.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff including the Facility Director and Program Director discussed via individual supervision and at our D&A staff meeting held on Monday, September 22,2014 the citation of each identified charts and plans of correction which includes: 1)Each counselor will document in the charts (ROC)Report of Contact the reason for not providing counseling services to the consumer, counseling offered for that week or what the counseling service indicates with primary counselor or another counselor (accepted or declined). 2) Weekly random chart checks will be completed by Clinical Supervisor or Facility Director to ensure info is being documented. 3) Add to 30, 60, 90 day chart check forms a check off process the proper service is being offered is in the charts. If the documentation is not present the primary counselor will make appropriate changes. |