INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 23, 2010 and February 24, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Berks Counseling Center, 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 and a plan of correction is due on March 19, 2010.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of project reports, personnel records, staff development records and interviews the project failed to establish individualized training plans annually.
Findings:
A review of the staffing requirements facility summary report, personnel records, staff development records and an interview with the clinical director on February 24, 2010 documented six of twenty-four staff failed to have written individualized training plans annually. Project policy and procedure require annual written individualized training plans be developed and documented in the staff development records by July 31 of each year.
Employee review # 1. The employee was hired on March 16, 1992. The training plan was to be documented by 07/31/2009. The training plan was not documented until 02/23/2010.
Employee review # 4. The employee was hired on October 14, 2008 The training plan was to be documented by 07/31/2009. The training plan was not documented until 02/07/2009.
Employee review #5. The employee was hired on November 14, 2005 and promoted to clinical supervisor on November 2009. The training plan was to be documented by 07/31/2009. The training plan was not documented until 02/06/2009.
Employee review # 10. The employee was hired on May 29, 2008. The training plan was to be documented by 07/31/2009. The training plan was not documented until 02/10/2009.
Employee review # 19. The employee was hired on August 1, 2004 with a change in position on May 1, 2007. The training plan was to be documented by 07/31/2009. The training plan was not documented until 02/10/2009.
Employee review # 20. The employee was hired on May 12, 2009. The training plan was to be documented by 07/31/2009. The training plan was not documented until 10/09/2009.
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Plan of Correction
Clinical Director will assume responsibility for having Annual Written Individualized Training Plans completed by staff and supervisors during the month of June and turned in to personel files by June 31st of each fiscal year, beginning with June, 2010.
Clinical Director will monitor compliance to this policy and procedure. |
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 reports, client records and interviews, the project failed to maintain outpatient caseloads at or below 35:1.
Findings:
A review of the staffing requirements facility summary report, census reports, client records and an interview with the clinical director on February 24, 2010, revealed that the project assigned one of twelve counselors with 41 active cases. A review of the census reports and staffing requirements facility summary report on February 23, 2010 identified counselor # 7 with an active caseload assignment of 41 clients on February 23, 2010 and February 24, 2010.
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Plan of Correction
Clinical Director and Therapist #7's direct Clinical Supervisor have reviewed therapist #7's caseload and transferred 8 of the consumers on his case load to new therapist who began employment, at BCC, on March 8th.
Therapist #7's Clinical Supervisor will continue to monitor his caseload to ensure he/she
and discharges consumers from his /her caseload in a timely manner so they do not appear active when they are not.
This procedure has started March 1, 2010.
Clinical Supervisors will routinely check on caseload numbers with staff during weekly supervision beginning March 1, 2010.
QA committee will check on case load numbers randomly through out the year to ensure compliance beginning April 1, 2010. |
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.
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Observations
Based on a review of reports, client records and interviews, the project failed to notify the Department of the change in authorized maximum capacity.
Findings.
A review of the staffing requirements facility summary report, census reports, client records and an interview with the clinical director on February 24, 2010 documented the project was in excess of the authorized capacity of 250 clients. A review of the census reports and staffing facility summary report on February 23, 2010 identified the project census of 276. The project was over the authorized capacity by 26 clients on February 23, 2010 and February 24, 2010.
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Plan of Correction
Deputy Director will request an increase to BCC's capacity from 250 to 300 by March 26, 2010.
BCC anticipates increase in capacity will be granted by May 1, 2010.
An additional full time therapist started at BCC on March 8, 2010 which enabled Clinical Director to redistribute some of the consumers on distribution of client admissions.
BCC has also increased the outpatient hours of current part time therapist by 15 hours as of March 15th, 2010. This is also to help assume redistribution of client admissions.
BCC has sufficient office space to house the additional therapists.
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