INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 13, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, PA Treatment & Healing 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirement Facility Summary Reports (SRFSR), the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings inclued:
The Staffing Requirements Facility Summary Reports for the 11 facilities contained within the project were reviewed on August 25, 2015. The equivalent of 12 full-time counselors are employed within the project. This would require at least 1 full-time clinical supervisor.
The project ' s SRFSRs listed a total of 1 clinical supervisor, who also was listed as a counselor; therefore, they are unable to provide full-time clinical supervision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current Clinical Supervisor will reduce her caseload by transferring the majority of her cases to the other counselors at the Honesdale location so as to not increase the other counselors caseloads out of compliance. The current Clinical Supervisor will maintain a caseload of no more than 5 clients on her caseload in order to be able to provide full time clinical supervision. This standard will be in compliance by 9/21.2015. Ongoing compliance with this standard will be ensured through oversight and supervision by the Facility and Project Directors. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes follow-up information in four of ten client records reviewed.
The findings include:
Ten client records were reviewed on August 13, 2015. Five client records required documentation of a follow-up attempt. The facility failed to document a follow-up attempt in client records, #5, 6, 7 and 9.
Client #5 was admitted into treatment on October 14, 2014 and was discharged on April 16, 2015. As of the date of the licensing inspection, the facility failed to document a follow-up attempt in client record #5.
Client #6 was admitted into treatment on September 22, 2014 and was discharged on January 8, 2015. As of the date of the licensing inspection, the facility failed to document a follow-up attempt in client record #6.
Client #7 was admitted into treatment on November 25, 2014 and was discharged on May 5, 2015. As of the date of the licensing inspection, the facility failed to document a follow-up attempt in client record #7.
Client #9 was admitted into treatment on September 18, 2014 and was discharged on November 21, 2014. As of the date of the licensing inspection, the facility failed to document a follow-up attempt in client record #9.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to the findings after the inspection a staff meeting was held to review PATH Policy pertaining to Discharge follow up letters and DDAP standards pertaining to Discharge follow up letters. An action plan was put into place as of Sept 1, 2015 to avoid future issues in this area and upon discharge letters will be generated by the Counselor and the Secretary will be responsible to mail the letters due monthly. Counselors of clients # 5,6,7,and 9 were instructed as of Sept 1, 2015 to complete follow up letters and send. It will be the responsibility of the Clinical Supervisor to ensure upon discharge Follow Up Letters are completed as part of the discharge paperwork and handed to the Secretary to be mailed on the months due. |