INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on August 30, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Clearfield Jefferson Community Mental Health, Inc. were partially substantiated. The following deficiencies were identified during this investigation.
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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 administrative documents, client caseload lists, billing records and client sign in sheets and client billing records, the facility failed to to ensure that each caseload was in compliance with the 35:1 caseload requirement.
The findings included:
Caseload lists for each counselor were reviewed during the 8/30/2011 unannounced complaint investigation. Two types of lists were generated. One set of lists came from the administrative offices of Clearfield Jefferson Community Mental Health Center administrative offices in Dubois and one set of lists came from the individual counselors' personal caseload lists. The numbers on the administrative lists for each caseload were inconsistent with the numbers on the caseload lists generated by each of the counselors.
This facility typically employs three counselors. The loss of one counselor for an indeterminate period of time has resulted in the caseloads of the two remaining counselors exceeding the 35 maximum caseload requirement. Based on a review of the lists, a comparison with the client sign in sheets for each day and interviews with clinical and administrative staff on site, the caseload for one counselor was 41 clients and for the caseload for the second counselor was at 48 clients.
The findings were reviewed with the clinical director and were not disputed.
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Plan of Correction
The agency is in the process of hiring an additional staff person to cover the caseload of the therapist that is off on medical leave. Due to the unexpected medical emergency of a therapist, the agency was waiting for an official medical directive prior to making any decisions regarding caseloads and staffing issues. However, all cases have been reviewed clinically and all consumers that were appropriate for discharge have been discharged. The clinical supervisor will continue to monitor this area and hire additional staff as the need arises. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on a review of administrative documents, client caseload lists, billing records and client sign in sheets and client billing records, the facility failed to demonstrate an efficient data retrieval system which accurately reflected each counselor caseload on a daily basis.
The findings included:
Caseload lists for each counselor were reviewed during the 8/30/2011 unannounced complaint investigation. Two types of lists were generated. One set of lists came from the administrative offices of Clearfield Jefferson Community Mental Health Center administrative offices in Dubois and one set of lists came from the individual counselors' personal caseload lists. The numbers on the administrative lists for each caseload were inconsistent with the numbers on the caseload lists generated by each of the counselors.
Based on a review of the lists, a comparison with the client sign in sheets for each day and interviews with clinical and administrative staff on site, the caseload for one counselor was 41 and for the second counselor was 48.
The information on the daily client sign in lists, the individual counselor caseloads on the two types of lists generated by the facility and the counselors' billing reports, were all contradictory. Determining an exact active caseload number for each counselor was challenging and imprecise. Client sign in lists were labeled "D&A" but, based on a review of the data with the clinical supervisor, some of the clients who signed in on the D&A list were actually attending forensic groups or "Reg" groups that were not D&A oriented. A data collection and record-keeping system that allowed for the efficient retrieval of data regarding outpatient caseloads was not available.
The findings were reviewed with the clinical director and were not disputed.
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Plan of Correction
The Center will ensure that all drug and alcohol clients are accurately reflected on official caseload lists, to include cases transferred amongst therapists. To ensure accuracy of the official caseloads lists, the Department Director will review, on a weekly basis during individual supervision, the official caseload list with individual clinicians to ensure accuracy. In the event of staff turnover or staff inability to provide treatment, consumers will be transferred to a new clinician and will be actively reflected on the caseload of the clinician referred to. |