INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 16, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Hispanic American Organization, 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.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training during the facility's January 2022 through December 2022 training year in one of three applicable personnel records reviewed.
Employee # 3 was hired as a counselor on May 11, 2021. The personnel record documented 11 hours of annual training for the reviewed training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The organization clinical supervisor will monitor quarterly, during supervision that all staff be attending training as delineated in the latest Annual Training plan to maintain compliance with the
25 hrs. of training annually.
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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 the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that the full time equivalent (FTE) counselor caseload in outpatient programs did not exceed 35 active clients in one of four applicable personnel records reviewed.
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, to obtain the FTE ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee # 4 was hired as a counselor on January 20, 2020. The employee's ratio calculation was as follows: 20/40 = .5 (FTE); 20/.5 = 40, which equals to a client/counselor FTE ratio of 40:1.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The organization and the program Director will develop a Policy on employed the employee manual that address that 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, to obtain the FTE ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
This policy will be complete by May 30, 2023. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in five of seven applicable client records reviewed.
Client #2 was admitted on August 17, 2022 and was still active at the time of the inspection. A treatment plan update was completed on December 12, 2022 and an update was due no later than February 12, 2023; however, the update was not completed at the time of inspection.
Client #3 was admitted on August 23, 2022 and was still active at the time of the inspection. A treatment plan update was completed on December 23, 2022 and an update was due no later than February 23, 2023; however, the update was not completed until at the time of inspection.
Client #5 was admitted on July 13, 2022 and was discharged January 16, 2023. A treatment plan update was completed on November 10, 2022 and another update was due no later than January 10, 2023; however, the update was not completed prior to discharge.
Client #6 was admitted on May 5, 2022 and was discharged December 19, 2022. A treatment plan update was completed August 17, 2022 and another update was due no later than October 17, 2023; however, the update was not completed prior to discharge.
Client #7 was admitted on April 26, 2022 and was discharged on October 31, 2022. A treatment plan update was completed August 22, 2022 and another update was due no later than October 22, 2023; however, the update was not completed prior to discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will be Monitoring that all treatment care services will be review every 60 days to maintain compliance. Each case will have a plan of review for 60-120-and 180 as each individual case needed based on admission date. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include case consultation notes, in four of four applicable client records reviewed.
Client #4 was admitted on July 14, 2022 and was discharged January 30, 2023. The record did not document any case consultation notes at the time of the inspection.
Client #5 was admitted on July 13, 2022 and was discharged January 16, 2023. The record did not document any case consultation notes at the time of the inspection.
Client #6 was admitted on May 5, 2022 and was discharged December 19, 2022. The record did not document any case consultation notes at the time of the inspection.
Client #7 was admitted on April 26, 2022 and was discharged on October 31, 2022. The record did not document any case consultation notes at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The organization clinical supervisor and clinical staff will conduct consultations biweekly of all active cases, per case loads and will maintain a complete client record, which will include case consultation notes, on each applicable client records prior to 90 days of services. Documentation of all consultation will be included on client record. |