INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 14, 2008 and April 115, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Good Samaritan Center For Counseling Services 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 May 9, 2008.
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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, an interview with the facility director and census reports on April 14, 2008 the project failed to maintain outpatient caseloads under thirty-five active clients. Two of four counselors have caseloads in excess of thirty-five. One counselor had a caseload of thirty-seven active clients and one other counselor had a caseload of forty-six active clients.
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Plan of Correction
1. Review current caseload status for each counselor and either close or transfer patients to other administrative clinical staff to bring all staff into full compliance with maximum client/counselor ratios.
Date of Completion: 4/29/2008
Responsible Person: Facility Director
2. Run weekly census report of clinical caseload to ensure that counselor/client ratios remain within approved limits.
Date of Completion: 5/2/2008
Responsible Person(s): Facility Director/Clinical Supervisor
3. Existing clinical staff vacancies have been approved for hire, and posting of position will occur the week of May 5th, 2008.
Date of Completion: 5/9/2008
Responsible Person: Facility Director
4. Interview and select candidates and fill vacancies in order to ensure adequate staff are available to ensure ongoing compliance with client/counselor ratios.
Date of Completion: Ongoing to 5/30/08
Responsible Person: Facility Director |