INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 4-5, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Wes Corporation 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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704.12(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 October 28, 2014 and an interview with the senior director, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on October 28, 2014. The form listed one counselor, project director, and facility director as clinical staff .The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 37.5 hours per week.
Based 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, 37.5 or 35 as applicable), and the total number of clients assigned to the following employee on October 28, 2014 employee # 3 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 # 3 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 30 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee #3 had 40 active clients on January October 28, 2014.
Employee # 3 (30/35 = .857FTE 40 clients/.857 FTE = 47:1 caseload)
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program went through staff transition shortly before the audit where three staff members left employment from the program. This left us with one clinical employee and Program Director.
On 11/10/14, new Clinical Supervisor has taken a caseload of 12 clients. Employee #3 caseload has been decreased from 40 clients to 28 clients allowing for a 33:1 ratio size:
Employee #3 (30/35 = .857FTE
28 clients/.857 FTE = 33:1
To ensure staff caseloads exceeding 35:1 do not recur, the facility director has hired a New Clinical Supervisor to the program as of 11/10/14. If transition such as the above were to occur again in the future, the clinical supervisor who is able to provide clinical treatment to clients, as well as facility director will take up a caseload as necessary to insure staff to client ratio remains under 35:1.
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on November 5, 2014 , the facility failed to ensure that all heaters were permanently mounted or installed.
The findings include:
Two space heaters were observed during the physical plant inspection. One was in a case management office and another in the facility directors office.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/7/14, all space heaters were removed from the offices under the supervision of facility management.
To insure this does not recur, a memo has been drafted and circulated on 12/8/2014 to notify all staff that space heaters are not allowed in any office within the facility building unless permanently mounted or installed. Each staff member was required to sign-off that they were in receipt of the memo.
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