INITIAL COMMENTS
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This report is a result of an administrative review conducted on September 10-12, 2019, September 17-19, 2019, and an on-site licensure renewal inspection conducted on September 24, 2019, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. Girard Satellite Office 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)(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 and staff interviews conducted during the on-site inspection, the facility failed to ensure that outpatient counselor caseloads did not exceed a 35 to 1 client to counselor ratio.
Staff Person #3, a counselor, had a client to counselor ration of 36 to 1.
The full-time equivalent (FTE) is determined by diving the weekly hours a counselor or counselor assistant devotes to drug and alcohol treatment services by the facility's work week.
Staff Person #3 devotes 24.5 hours a week on drug and alcohol treatment services, and the facility's work week is 37.5 hours a week. 24.5 / 37.5 = .6533 (FTE)
The client to counselor caseload is determined by dividing the active number of clients for a counselor by the FTE and rounding the number up to the nearest whole number.
Staff Person #3 had a caseload of 23 active clients. 23 / .6533 = 35.2 (36 to 1)
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The facility was unaware that the Department had begun using a new standard calculation for determining caseload and therefore we were utilizing the one that was on the current staffing sheets. The Inspector informed us of the new formula.
From this point forward we will utilize the new formula to manage caseload and ensure that no counselor is above the standard 35:1 ratio set forth in standards. The current caseload will be corrected by adding site hours to the Girard location. |