INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on March 6-8, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Polaris Renewal Services 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 the 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
The facility failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.The Staffing Requirements Facility Summary Report was reviewed on March 6-8, 2017. The equivalent of 8.5 full-time counselors are employed within the facility. This would require at least 1 full-time clinical supervisor. The facility does not employ a full-time clinical supervisor.These findings were reviewed with facilty staff during the licensing process.
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Plan of Correction
The Facility Director will be responsible for ensuring that a full time clinical supervisor will be employed for every 8 full time counselors or counselor assistants. The Facility Director has promoted the Lead Counselor to the role of full time Clinical Supervisor. The Clinical Supervisor will maintain a caseload of no more than 5 patients. The Facility Director is responsible for maintaining staffing requirements. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
The facility failed to document that the lead counselor completed the core curriculum training in clinical supervision in one of one personnel record reviewed on March 6-8, 2017. Personnel record #2 was promoted to lead counselor on January 1, 2016. As of the date of the review, there was no documentation provided that the lead counselor had completed the required training.
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Plan of Correction
The Facility Director is responsible for ensuring that The Clinical Supervisor/Lead Counselor completes the core curriculum training in clinical supervision. The Clinical Supervisor is currently entombed in the training to be held April 24-28. The Facility Director will be responsible for documenting training attendance and completion in the Supervisor's personnel file.
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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
The facility failed to ensure that staff caseloads remained at or under 35:1 in eight of nine staff caseloads reviewed on March 6-8, 2017. The Staffing Requirements Facility Summary Report form completed by the facility on 3/6/17 listed nine counselors and the project director/facility director as clinical staff . Counselor # 2 had an FTE caseload of 39:1Counselor # 3 had an FTE caseload of 43:1Counselor # 4 had an FTE caseload of 45:1Counselor # 5 had an FTE caseload of 42:1Counselor # 6 had an FTE caseload of 41:1Counselor # 7 had an FTE caseload of 49:1Counselor # 9 had an FTE caseload of 38:1Counselor # 10 had an FTE caseload of 38:1These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Polaris Renewal Services will continue to hire an adequate number of staff to comply with current census and to maintain a 35:1 counselor to patient ratio. Since the March 8 inspection, Polaris has hired 2 full time counselors that will carry a caseload of 35. Polaris has also extended an offer of employment to 2 full time therapists. Polaris is also decreasing census through attrition and patient requested transfers Polaris is not accepting any new patients until there is adequate staff to meet the 35:1 ratio. The Facility Director is responsible for the recruitment, interviewing, and hiring of qualified clinical staff to ensure staff caseload ratios do not exceed 35:1. The Facility Director is also responsible for consistently maintaining the approved caseload ratios. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the 2015 fiscal year. The facility's administrative records were reviewed for documentation of the annual audit on March 6-8, 2017. The project did not document an independent financial audit for 2015.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will obtain an annual audit from an independent accountant each year. This has already been corrected and a financial audit for fiscal year 2016 was conducted by Houstan & Associates. The CEO is responsible for initiating and approving the commencement of an annual financial audit by an independent accountant. The Polaris Business Manager is responsible for providing all needed financial documents to the independent accountant. The Facility Director is responsible for reviewing the regulatory audit requirements with the CEO and Business Manager to ensure that an annual audit is completed. |