INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on 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, 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
During a licensing inspection and Staffing Requirements Facility Summary Report review conducted on December 3, 2019, the facility failed to comply with the client/staff and client/counselor ratios in paragraph (6) during primary care hours.
Employee # 2 was hired as the Clinical Supervisor on May 30, 2014. Employee # 2 reported to have 5 hours per week devoted to their 5 clients on their caseload. The FTE counselor ' s caseload calculation is as follows: 5/40 = .125(FTE); 5/.125= 40, which equals to a client/counselor ratio of 40:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CD in this case did meet the 35/1 ratio, the RCD filled out these reports incorrectly writing 5/5 rather than the hours allotted for client hours. The Director reviewed with RCD how to complete her staffing requirements. The Director will oversee that these staffing requirements are completed correctly and assure that all staffing are meeting the 35/1 ratio by having the RCD monitor compliance weekly with the clinical directors to ensure they are meeting the 35/1 ratio.To ensure compliance the RCD will send a weekly report of the ratios to ensure compliance. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
During a licensing inspection conducted on December 3, 2019, the project failed to obtain an informed and voluntary consent to disclose form to include a purpose for disclosure in one of seven records reviewed.
Client # 5 was admitted on July 24, 2019 and discharged on October 26, 2019. An informed and voluntary consent to disclose form to "Bail Officers" did not have a purpose for disclosure provided.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 12/3/2019 the management team met to review deficiencies. The CD of each facility reviewed confidentiality with each staff member in staff meeting held on 12/6/2019. The Training/HR director will hold a training on confidentiality and how to fill out releases of information including HIPPA laws with all staff on 1/10/2020 and again in Summer of 2020, specific date to be determined in April of 2020. The CD will review all intake charts on Fridays and provide corrective direction if and when necessary. The RCD will review at least 5 charts per week in each facility to determine compliance. |
709.28 (c) (5) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
During a licensing inspection conducted on December 3, 2019, the facility failed to provide a complete voluntary and informed consent to disclosed form to include a witness signature in one of seven records reviewed.
Client # 2 was admitted on November 5, 2019 and was still active at the time of the inspection. Three informed and voluntary consent to disclose forms to a "Fianc dated November 5, 2019, to a "Probation Officer" dated November 5, 2019, and a "Funding Source" dated November 5, 2019 did not have a dated signature of a witness.
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Plan of Correction
The management team met to review the deficiencies on 12/3/2019. The CD reviewed the deficiencies of confidentiality in staff meeting held on 12/6/2019. The Training/HR director will provide a training on this process again with all staff on 1/10/2020. The Training/HR director will provide another training in Summer of 2020. Date to be determined in April of 2020. The CD is responsible for reviewing all active charts to ensure compliance of confidentiality and complete new forms if necessary by 12/15/2019. The RCD will review 5 charts per week per facility, to ensure continued compliance. The CD is responsible for reviewing all new charts on Fridays to ensure compliance of confidentiality and address areas of deficiency immediately. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
During a licensing inspection conducted on December 3, 2019, the project failed to provide a termination letter to include the reason for termination and the right to appeal in one of seven records reviewed.
Client # 1 was admitted on June 5, 2019 with an unknown discharge date. A progress note dated November 21, 2019 indicated sending a termination letter to notify discharge, however there was no record of a termination letter in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The management team met to review the deficiencies on 12/3/2019. The CD reviewed the discharge process with all clinical staff in staff meeting held on 12/6/2019. The Training/HR director will provide a training on this process again with all staff on 1/10/2020. The Training/HR director will provide another training in Summer of 2020. Date to be determined in April of 2020. The CD is responsible for reviewing compliance with all clients who have not been seen in over 15 days. The RCD will review 5 charts per week per facility, where clients have not been seen in 15 days to ensure compliance. |