INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 24 through January 27, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Genesis House, Inc. 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
February 24, 2011.
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Plan of Correction
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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 a review of client records and a discussion with the project director, the facility failed to document follow-up attempts in three of the six required records.
The findings include:
On January 25-26, 2011, six client records were reviewed for follow - up attempts. The facility failed to document follow up attempts in three of the six required client records reviewed.
The facility policy titled Protocol for Follow-up Activity states: "Follow-up on client treatment progress will be completed on each discharged client using phone calls and mailed follow-up forms upon 3 months, 6 months and 1 year after discharge. Designated staff will make three contact attempts with each client at each designated interval." The policy statement details each step involved. In addition the policy covers, Against Medical Advice (AMA), Administrative, and Transfer discharges. "Follow-up on clients who have dropped out of treatment AMA, who have been administratively discharged, or who have been transferred to another facility will be completed within one week of last date of service. Attempt to re-engage the client in the treatment process or whether or not the client followed through with the referral appointment will be documented via a progress note indicating a follow-up contact by the primary counselor."
Client record # 13 failed to include documentation of a follow up attempt. Client # 13 was admitted on 2/11/10 and discharged on 12/23/10 as AFA. The follow up attempt was due on 12/30/10.
Client record # 15 failed to include documentation of a follow up attempt. Client # 15 was admitted on 4/28/10 and discharged on 12/23/10 as successful. The follow up attempt was due on 3/23/11.
Client record # 16 failed to include documentation of a follow up attempt. Client #16 was admitted on 6/26/08 and discharged on 3/30/10 as successful. The follow up attempt was due on 6/30/10.
The project director confirmed that the follow up attempts in these client records were not documented at the time of the licensing inspection.
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Plan of Correction
Project director will review the agency's follow up procedures for both AFA and successful discharges with clinical staff on 2/4/11 during the weekly clinical staff meeting to ensure their understanding.
Project director will review the follow procedures for successful completion with the designated agency staff assiganed this task on 2/4/11 to ensure their understanding and review issues noted during inspection in regards to implementation of the procedures to ensure compliance.
Lead counselor will monitor follow up completion on a monthly basis beginning 2/28/11 and discuss any issues noted with the project director to ensure consistent compliance. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the staffing requirements facility summary report and active client list, the facility failed to notify the Department of a change in authorized maximum capacity.
The findings include:
The staffing requirements facility summary report was reviewed on January 25, 2011. The summary report, signed by the Project/Facility Director, indicated the facility had 202 current clients. The facility is licensed by the Division for a maximum client capacity of 192.
The Facility Director acknowledged that the facility was currently over the authorized client capacity of 192.
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Plan of Correction
Project director will monitor facility's active client list on a weekly basis to ensure his awareness beginning 2/11/11.
Project director will notify the division requesting a change in the facility's maximum capacity should the client numbers or staffing pattern deem that appropriate by 2/28/11. |
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 January 25, 2011 and a discussion with the facility director, the facility failed to ensure that counselor outpatient caseloads were at or below 35 active clients per one Full Time Equivalent (FTE) counselor.
The findings included:
On January 25, 2011 four counselor outpatient caseloads were reviewed on the facility summary report form. Per regulation, the caseload for counseling in outpatient programs may not exceed 35 clients per one FTE counselor. Based on the number of hours the employees worked at this facility, and the number of clients on the counselors' caseload, four counselors exceeded the maximum outpatient caseload of 35:1. One counselor had a caseload of 53:1, one counselor had a caseload of 49:1, one counselor had a caseload of 51:1, and one counselor had a caseload of 45:1.
This was discussed with the facility director on January 25, 2011. The facility director confirmed these counselors were over the required caseload of 35:1.
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Plan of Correction
Project director will hire an additional full time counselor for the facility to reduce the client caseloads in question to a level which is at or below the mandated ratio by 2/7/11.
Project director will then monitor staff/client ratios on a weekly basis and address either referral intakes or staffing pattern to ensure consistent compliance beginning 2/11/11. |