INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on January 16, 2020 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site complaint investigation, New Perspectives at White Deer Run was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
704.12(a)(1)(i) LICENSURE Client/couns ratios
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.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
|
Observations
The facility failed to maintain the primary care staff to client ratio in the detoxification activity.
Based on a review of the Staffing Requirement Facility Summary Report it was determined that the facility was understaffed.
January 8, 2020: census - 8; primary care staff listed - 1
|
Plan of Correction
The facility nursing staff will complete daily census reports, which will be reviewed by the Campus Director and Nurse Supervisor to ensure primary care staff/client ratio does not exceed 7:1. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
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.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
|
Observations
The facility failed to maintain the counselor to client ratio in the nonhospital rehabilitation activity.
January 8, 2020 census: 33; FTE: 4; ratio: 9
|
Plan of Correction
In the event of an immediate termination (whether voluntary or involuntary) of a FTE with a caseload, the Campus Director will recruit assistance from another facilty's primary care staff while aggressively pursuing to fill the vacancy to ensure client/FTE ratio does not exceed 1:8. |
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.
|
Observations
The facility reported a census of 33 for the inpatient non-hospital residential activity and a census of 8 in the detoxification activity on January 8, 2020 which exceeds their authorized license capacity of 40.
|
Plan of Correction
The facility nursing staff will complete daily census reports, which will be reviewed by the Campus Director and Nurse Supervisor to ensure primary care staff/client ratio does not exceed 7:1. |