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 June 16, 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, Aldie Foundation Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiency was identified during this inspection:
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Plan of Correction
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Observations
Based on a review of the Staffing Requirement Facility Summary Report, the facility failed to ensure that all outpatient counselors did not exceed the 35 to 1 counselor to client ratio in one of fifteen applicable counselors.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee #8 was hired as a counselor on October 21, 2019 and was still in the position. Employee #8's ratio calculation was as follows: 30/40 = .75(FTE); 27/.75 = 36, which equals to a client/counselor ratio of 36:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To resolve the deficiency of one counselor exceeding the 35 to 1 counselor to client ratio the following actions are being taken: One part-time counselor will start to work additional hours in the month of July and as such will assume a larger case load. In addition, Aldie is in the process of hiring another counselor. The new staff person will be able to have a case load of existing and new clients thereby ensuring the at ratio does not exceed 35 to 1 for any staff. The Clinical Director is conducting the interviews. The CEO will make the final decision to hire which is planned to occur by July 31, 2020.To ensure continued compliance the Clinical Director will monitor (on a not less than monthly basis) an internal staffing spreadsheet and adjust counselor caseloads accordingly so that the ratio does not exceed 35 to 1. In the event of a staff vacancy, recruitment of replacement staff will begin as soon as the vacancy is known and all efforts will be made to fill open position within 60 days. |