INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 20, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, SPHS Behavioral Health 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
The facility failed to ensure that outpatient staff caseloads remain at or under 35:1.
Based on the total number of hours per week devoted to clients, and the facility's standard work week of 37.5 hours, employee #5, exceeded the allowable maximum 35:1 caseload.
As reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 5 to outpatient client treatment was 3 contract hours per week. The employee had 3 active clients as of February 20, 2020.
Employee # 5 (3/37.5 = .08 FTE *** 3 clients/.08 FTE = 37.5 - 38/1 caseload)
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director advised Clinical Supervisor to add a "Caseload" discussion point to DA Staff Meeting form to check caseload ratios on a weekly basis with counselors. For counselors who did not attend the DA Staff Meeting, they will be required to review at a scheduled time with the Program Supervisor. Clinical Director explained new recruitment and hiring strategies with Program Supervisor who will be more proactive in ensuring the supply of counselors with respect to the volume of clients at the facility. These changes occurred on 2/27/2020. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to document that unusual incident reports were sent to the Department within 3 business days following incidents involving the presence of an ambulance.
The unusual incident reports were reviewed on February 20, 2020. There was one unusual incident that occurred on May 14, 2019 in which an ambulance was called. There was no documentation that the unusual incident report was sent to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director explained that Program Supervisors will be required to inform the Program Director of any unusual incident from this point forward. Program Director will decipher whether or not the unusual incident report needs to be forwarded along to DDAP. If the unusual incident report aligns with DDAP criteria, the Program Director will submit the report electronically as encouraged by the licensing inspector. Program Director already has setup login information to do so. In the event that an unusual incident occurs on a day that Program Supervisor and/or Program Director are unavailable, backup manager designees will be assigned to submit the unusual incident report electronically in lieu of the primary supervisor/director, and an email to the primaries regarding the occurrence of this event will be sent by the covering manager. These changes have gone into effect as of 3/4/2020. |