INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 16, 2010 through August 18, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Self Help Movement, Inc. 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 and a plan of correction is due on September 13, 2010.
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Plan of Correction
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704.12(a)(3)(i) LICENSURE NonHosp Rehab
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.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report submitted by the facility director and a review of the clinical staff hours as well as an interview with the project director, the facility failed to ensure that the staff to client ratio remained at or below one full time equivalent (FTE) counselor for every eight clients, as required by regulation.
The findings include:
The client census information and clinical staff complement documented on the "Staffing Requirements Facility Summary Report", which was signed by the facility's Director of Administration on August 16, 2010, demonstrated that the client to counselor ratio was at 8.32:1 overall for the residential rehabilitation treatment track and the halfway house treatment track- which was over the 8:1 ratio permitted for an inpatient nonhospital treatment and rehabilitation activity serving adult clients.
The information reported on the "Staffing Requirements Facility Summary Report" indicates that there were 13 full time counselors and/or counselor assistants, one full time clinical supervisor and one part time clinical supervisor who contributed 20 hours toward the clinical treatment services for both treatment tracks. The "Staffing Requirements Facility Summary Report"shows that 8 of the nine staff working in the halfway house treatment track, at 25 hours each, are also full time counselors or counselor assistants with the residential rehabilitation track. When the ratios for the treatment tracks were computed separately, the ratio for the halfway house treatment track was at 8.53:1, which was over the 8:1 client to counselor ratio permitted by the standard.
This was discussed with facility staff on an ongoing basis and during the exit interview.
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Plan of Correction
Self Help Movement was minus a counselor for a short period of time. Since that time the complement of counselors has increased and the facility will no longer exceed the 8:1 ratio either in the halfway house or the inpatient treatment programs. The Director of Treatment Services and Assistant Director of Treatment Services will monitor for ongoing compliance. This took effect on 9/7/10. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on inspection results, staff interviews and a review of client records, the facility failed to review and update treatment and rehabilitation plans every 30 days.
Findings:
On August 18, 2010 eight active client records were reviewed. Six of the eight records required treatment and rehabilitation plan updates. Two of six records did not include documentation of the treatment and rehabilitation plan updates.
Client record # 1 - Admitted on May 10, 2010. The treatment plan was established on June 10, 2010. The treatment plan review and update was due on July 10, 2010. A review of record #1 on August 18, 2010 revealed that the record did not include documentation of a treatment plan review and update for July 10, 2010. The treatment plan update and review in client record # 1 was late by thirty eight days.
Client record # 6 - Admitted on April 13, 2010. The treatment plan was established on April 27, 2010. The treatment plan review and update was due on July 27, 2010. A review of record #6 on August 18, 2010 revealed that the facility failed to document a treatment plan review and update for July 27, 2010. The treatment plan update and review was late by twenty one days.
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Plan of Correction
Effective 8/18/10, clinical files will be monitored by the Director of Treatment and the Assistant Director based on deadline dates for client treatment levels and length of stay. Our compliance officer and assistant director will prepare deadline lists for each counselor upon client admittance to assure timely completion, review and signatures which will then be signed off on by the Director of Treatment. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on inspection results, staff interviews and a review of client records, the residential rehabilitation facility failed to document complete client records to include follow-up information in five of seven client records.
Findings:
On August 18, 2010 eight closed client records were reviewed. Seven of the eight records were required to include documentation of attempts to follow-up on the clients. Client records # 1, 2, 3, 5 and 7 failed to include documentation of follow-up information as required by facility policy.
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Plan of Correction
Effective immediately, all successfully discharged clients will have a contact note on the aftercare follow-up form to verfity client's attendance or non-attendance of outpatient or aftercare programs. This will be completed and documented within 7 days of the client's appointment. Our compliance officer and assistant director of treatment will coordinate and assure completion and documentaiton of this task as required. |