Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" for all of the facilities in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.
The findings include:
The "Staffing Requirements Facility Summary Reports" for the five facilities that make up the project list a total of 22 counselors (some full time and some part time) and one clinical supervisor. The total of the hours per week provided to the project by counselors equates to 17 FTE counselor positions within the project.
The "Staffing Requirements Facility Summary Reports" for the five facilities within the project revealed that only one employee was listed as a full-time clinical supervisors; however, the clinical supervisor was documented as having a caseload of 33:1. Therefore the clinical supervisor can only be considered as a part-time clinical supervisor. A full-time equivalency of 17 counselors would require a minimum of 2 full-time clinical supervisors and one part- time clinical supervisor within the project.
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Plan of Correction
Minsec's project manager/VP of Operations will ensure that qualified individuals are hired to serve as a clinical supervisor in order to meet the standards set forth by PA code 704.6. In order to prevent this deficiency from occurring again the Project Manager will ensure that the Clincial Supervisor positions will be staffed to meet the ratio of one full-time clinical supervisor for every eight full-time counselors. The project manager/VP of Operations will also routinely montior the toal number of counselors to ensure that proper supervision coverage is met. This will begin as of 7/12/12. |
Observations
Based upon a review of client records, the facility failed to update treatment plans every 60 days.
The findings include:
Four records requiring documentation of treatment plan updates were reviewed on January 19, 2012. Three out of four records, specifically record #'s 3, 5, and 6, contained treatment plan updates that were late.
Client # 3 was admitted on September 6, 2011, and was still a current client at the time of inspection. Record # 3 contained a treatment plan update that was dated December 20, 2011, but that was due no later than December 6, 2011.
Client # 5 was admitted on June 2, 2011, and was discharged on November 23, 2011. Record # 5 contained a treatment plan update that was dated August 30, 2011, but that was due no later than August 19, 2011.
Client # 6 was admitted on March 24, 2011, and was discharged on September 7, 2011. Record # 6 contained two treatment plan updates that were late. The first treatment plan update was dated June 15, 2011, but was due no later than June 12, 2011. The second treatment plan update was dated August 31, 2011, but was due no later than August 11, 2011.
The findings were reviewed with the Facility Director and Clinical Supervisor during the exit interview.
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Plan of Correction
The Program Director/Clinical Supervisor will complete a random review of clinical records on a monthly basis to ensure that treatment plan updates are completed in a timely fashion. The Program Director/Clinical Supervisor will also review a sample of five charts during weekly supervison to ensure that treatment plan updates are completed and signed by all parties within the time frame in which treatment plan updates are due. |