INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 14 through 15, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clear Concepts Counseling 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 May 19, 2008.
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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 April 14 through 15, 2008 review of facility administrative records, the facility failed to maintain a 35:1 client to counselor ratio for one employee, #3. Employee # 3 had a caseload of 42 clients.
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Plan of Correction
Our facility will be in full compliance with this regulation by 5/15/08. The number of clients assigned to employee #3 will be reduced in order to achieve the 35:1 client to counselor ratio. The Clinical Supervisor will review this employees caseload on a regular basis during individual supervision to ensure this doesn't happen again in the future.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a April 14 through 15, 2008 review of client records, the facility failed to document complete personal history in two of ten records reviewed, #1 and 6. The personal history was missing the employment/vocation, educational and recreational histories in one record # 1. The personal history was missing in one record, #6.
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Plan of Correction
Our facility will be in full compliance with this standard by 5/15/08. Necessity of addressing all areas required by the guidelines will be reviewed with all staff at our next staff meeting (05/8/08). The Clinical Supervisor will also review this area with all counselors in individual supervision as an added measure to insure compliance. Additionally, we've restructured the process for clients who move immediately to IOP in order to better address this issue. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a April 14 through 15, 2008 review of client records, the facility failed to document a complete psychosocial evaluation in three of ten records reviewed, # 1, 2 and 6. Psychosocial evaluations were missing an assessment of the clients assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and client's attitude toward treatment.
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Plan of Correction
Our facility will be in full compliance with this standard by 5/15/08. This standard and our agency policy relative to this standard will be reviewed with all counselors at our next staff meeting on 5/8/08. The proper completion and timing of completion of the psychosocial evaluation will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance |