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 April 13, 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, Catholic Charities Counseling and Adoption Services, 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:
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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
The facility failed to maintain outpatient caseloads at or below 35/1.
The Staffing Requirements Facility Summary Report was reviewed on April 13, 2020. Counselor #3 had a caseload of 38/1. The breakdown is as follows:
Counselor #3 works 35 hours in the D/A treatment activity. The facility workweek is 37.5 hours. 35/37.5 = .93 FTE. Counselor #3 has a caseload of 35. 35/.93=37.63. The caseload for Counselor #3 is 38/1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 5/1/2020, each caseworker's caseload will correspond to our new understanding of how caseload totals are calculated by DDAP. Supervisor discussed this calculation process with workers - both counselors and supervisor will monitor caseloads to ensure that no worker takes on more than the allowed 35/1 ratio. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to maintain a written fire drill record which included the exit route used.
An inspection of the fire drill records was conducted on April 13, 2020. All of the fire drills conducted since January 2020 did not include the exit route used. The exit route used column was removed from the fire drill log form beginning in 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The agency has long used a form which clearly identifies the exit route used during each fire drill. When a new form was needed to record January, Feb & March fire drills, the wrong form was utilized. The Supervisor has corrected this error on 4/30/2020 and the form being used to record fire drill logs has all of the required elements on it. |