INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 22-23, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Arc Manor 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 2/26/16 and an interview with the facility 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 March 22-23, 2016. Based on the total number of hours per week that employees # 3, 7, 8, and 9 devoted to clients, and the standard work week of 35 hours, employees # 3, 7, 8, and 9 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 standard work week of 35 hours.
The number of hours per week devoted by Employee # 3 to outpatient client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 16.75 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 3 had 24 active clients as of 2/26/16.
Employee # 3 (16.75/35 = .4785 FTE **** 24 clients/.4785 FTE = 51:1 caseload)
The number of hours per week devoted by Employee # 7 to outpatient client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 16.75 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 7 had 28 active clients as of 2/26/16.
Employee # 7 (16.75/35 = .4785 FTE **** 28 clients/.4785 FTE = 59:1 caseload)
The number of hours per week devoted by Employee # 8 to outpatient client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 17.25 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 8 had 20 active clients as of 2/26/16.
Employee # 8 (17.25/35 = .4928 FTE **** 20 clients/.4928 FTE = 41:1 caseload)
The number of hours per week devoted by Employee # 9 to outpatient client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 16.75 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 9 had 26 active clients as of 2/26/16.
Employee # 9 (16.75/35 = .4785 FTE **** 26 clients/.4785 FTE = 55:1 caseload)
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Following the licensing visit, all client to staff ratios were reviewed and client to staff ratios are now in line with the standards for Outpatient clients for this location. A number of clients that were shown as active on the staffing list at the time of licensing submission, had been discharged and not taken out of the electronic health record. Once these cases were removed from the system, this made the ratios more in line with licensing regulations. In addition, some clients were transferred to therapists who were below the staffing ration, but able to carry a full caseload in order to better balance all staff to client ratios for outpatient services. Moving forward, the Clinical Director will maintain a "caseload reporting" spreadsheet to maintain the appropriate staffing ratios and this spreadsheet will be updated daily when new clients are assigned. In addition, for this Kittanning location, an additional therapist is being hired to accommodate the client needs to ensure that access standards are maintained while balancing client to staff ratios. This therapist is expected to start on 5/2/2016. |
709.28(c) 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 shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent in one of nine client records reviewed.
The findings include:
Nine client records requiring documentation of an informed and voluntary consent were reviewed on March 22-23, 2016. The facility failed to document an informed and voluntary consent in client record # 8.
Client # 8 was admitted into outpatient treatment on 10/15/15 and was still active at the time of the inspection. The client's record documented that the facility sent a fax to another treatment provider on 12/1/15, confirming the client's presence in treatment at the facility. A record of service for group sessions attended by the client was also faxed to the treatment provider. An informed and voluntary consent to this treatment provider was not documented in the client's record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will review this licensing citation with all clinicians in clinical staffing on Thursday, April 21, 2016 to reiterate the importance of maintaining and complying with the agency's confidentiality standards/procedures. Since this issue was directly related to one therapist, the issue will also be addressed in individual supervision with this therapist on Thursday, April 19, 2016. The Executive Director acts as this therapist's supervisor, therefore, it will be the Executive Director's responsibility to address this issue with the staff person individually. In addition, it is important to note that ARC Manor requires all staff to re-attend DDAP approved Confidentiality training every 2 years. The staff person involved in this error, attended and completed this Confidentiality training on April 7, 2016. The Assistant Director monitors all staff training to ensure compliance with all staff attending Confidentiality training every two years. Treatment supervisors are responsible for individual clinical compliance with this standard and will review 10% of client charts monthly during individual supervision to monitor this issue. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to document a physician signature on treatment plans, as imposed by 55 Pa. Code Part III, in one of nine client records reviewed.
The findings include:
Nine client records were reviewed on March 22-23, 2016. Two of the nine records reviewed were for outpatient treatment, and both outpatient records required the documentation of a physician signature on treatment plans. Treatment for the outpatient client records reviewed was funded through the Medical Assistance program. The facility failed to obtain a physician signature on treatment plans for client # 8.
Client # 8 was admitted into treatment on 10/15/15 and was still active at the time of the inspection. The client's treatment plan updates, dated 12/21/15 and 1/29/16, were not signed by a physician.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In response to this issue, the Medical Director was contacted following the licensing visit and was reminded to log into the EHR and review and sign all documentation in a timely manner. The process for physician signatures on EHR documents is that they are reviewed at least weekly to maintain timely signatures on all documents. The issue in both files identified was not actually with the physician, but with the treatment supervisor. The treatment supervisor had not yet reviewed and signed the documents in order to send them on to the physician for final signature. The Correction for this issue is that, during the April 26, 2016 Manager's meeting, the Executive Director will remind all treatment supervisors of the need to log into their alerts daily to sign off on any documentation. In addition, the Executive Director will have access to and be responsible for monitoring treatment supervisor and Medical Director alerts weekly through the Electronic Health Record. If the Executive Director determines that any party is falling behind in signing alerts/documentation (more than 10 documents unsigned at the end of each week) then a corrective action plan will be built with that individual for how to better manage this task and this corrective action will be documented in supervision notes. |