INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on September 21, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center For Addictive Disease - Main Line Affiliates, 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 October 22, 2010.
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Plan of Correction
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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 form completed by the facility on September 21, 2010 and an interview with the Project Director, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
On September 21, 2010 the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed the facility director and ten counselors as the clinical staff. The facility documented the facility director # 2 and nine counselors as having a caseload, employees # 3 thru 7 and 9 thru 12.
The facility director, employee # 2 had 2 clients and a caseload of 16:1, employee # 3 had 17 clients and a caseload of 34:1, employee # 4 had 7 clients and a caseload of 35:1, employee # 5 had 14 clients and a caseload of 17:1, employee # 6 had 34 clients and a caseload of 34:1, employee # 7 had 9 clients and a caseload of 36:1, employee # 9 had 33 clients and a caseload of 37:1, employee # 10 had 21 clients and a caseload of 32:1, employee # 11 had 12 clients and a caseload of 32:1, employee # 12 had 32 clients and a caseload of 32:1. Employee # 8 did not have a caseload.
The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based on the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week (40), and the total number of clients assigned to the following employees on September 21, 2010, employees # 7 and 9 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by the facility's standard workweek.
The number of hours per week devoted by Employee # 7 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 10 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 7 had 9 active clients on September 21, 2010.
Employee # 7 (10/40 = 0.25 FTE 9 clients/0.25 FTE = 36:1 caseload)
The number of hours per week devoted by Employee # 9 to client treatment, as reported by the facility on Staffing Requirements Facility Summary Report, was 36 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 9 had 33 active clients on September 21, 2010.
Employee # 9 (36/40 = 0.9 FTE 33 clients/0.9 FTE = 37:1 caseload)
During an interview, the Project Director confirmed that they had exceeded the allowable maximum caseload of 35:1 for counselor # 7 and 9.
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Plan of Correction
Caseload reports will be generated on a weekly basis and distributed along with weekly worked hours to intake workers in order to avoid going over ratio caseload for each individual therapist.
This process will be monitored weekly by the Clinical Director and monthly by the Director. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of three client records.
The consent shall be in writing and include, but not be limited to:
(i) The name of the person, agency, or organization to whom disclosure is made.
(ii)The specific information disclosed.
(iii) The purpose of disclosure.
(iv) The dated signature of the client or guardian.
(v)The dated signature of a witness.
(vi) The expiration date of the consent.
The findings include:
Three active client records were reviewed on September 21, 2010 for documentation of informed and voluntary consents from the client for the disclosure of information. The facility failed to document an informed and voluntary consent in one of three records, specifically record # 3.
Client record # 3 contained a consent to release information that was signed and dated; however, the consent failed to include the name of the person, agency, or organization to whom disclosure is made; the specific information disclosed; and the purpose of disclosure.
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Plan of Correction
No release of information will be signed prior to the name of the person, agency, or organization to whom disclosure is being made completed.
1. Monthly observation by Office Manager of paperwork process to ensure explanation of consents is being implemented according to policy and no release is left incomplete.
2. Internal chart audits, performed by Medical Records Tech, will include release of information completion. |