INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 22, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Perry Human Services, 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.
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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 and facility summary report form, the facility failed to ensure that staff to client ratios remained at or under 35:1.The findings included:On March 22, 2012, the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed each counselor's caseload. The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 37.5 hours per week.Based on the number of hours the employee worked at this facility and the number of clients on each counselor's caseload, two employees who provided counseling exceeded the maximum ratio of 35:1. The counselor represented as employee # 2 had a caseload of 39:1. The counselor represented as employee # 3 had a caseload of 37:1. The project/facility director confirmed that they had exceeded the allowable maximum caseload of 35:1 for employees #2 and 3.
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Plan of Correction
Project Director discussed with counselors #2 and #3 their client caseloads exceeded maximum allowable ratio of 35:1. Counselors #2 and #3 are working to decrease their caseloads to allowable ratio. Decrease will occur through discharges of clients who have completed their treatment and/or administrative discharges due to lack of attendance or other non compliances. Date for meeting allowable ratio for counselors #2 and #3 is May 15. Project Director will monitor weekly all counselors' caseloads to insure maximum ratio of 35:1 is not exceeded. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.The findings include:The letters of agreement were reviewed on March 22, 2012. There was no documentation of a 24-hour emergency medical coverage agreement with a licensed hospital or physician.The facility/project director was interviewed on March 22, 2012 and confirmed that that the facility did not have an agreement for 24-hour emergency medical coverage. A review of the presented documentation revealed that the facility had a signed agreement for 24-hour psychiatric coverage with a local hospital but did not have an an agreement for emergency medical services.
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Plan of Correction
Project Director contacted director of local licensed hospital regarding revision to letter of agreement between agency and hospital. Revision includes agreement for 24 hour emergency medical and 24 hour emergency psychiatric coverage through the hospital's emergency room. Letter of agreement sent to hospital director on April 10 for hospital director's signature. Projected date of compliance for new referral agreement is April 27. Project Director will insure that required referral agreement is maintained. |
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
Based on a review of client records, the facility failed to inform the client, in writing, of a decision to involuntarily terminate a client's treatment in three of three records reviewed. The findings include:Eight client records were reviewed on March 22, 2012. Three clients were involuntarily discharged and required the facility to notify the client, in writing, of the decision to involuntarily terminate a client's treatment at the project. The facility did not provide clients # 2, 3, and 5 with a notification in writing. Client # 2 was admitted to the program on March 10, 2011 and was involuntarily terminated from the program on August 2, 2011. The facility did not notify the client in writing of the reason for her termination from the program.Client # 3 was admitted to the program on May 12, 2011 and was involuntarily terminated from the program on July 25, 2011. The facility did not notify the client in writing of the reason for her termination from the program.Client # 5 was admitted to the program on February 14, 2011 and was involuntarily discharged on June 17, 2011. The facility did not notify the client in writing of the reason for his termination from the program.The finding was confirmed by the project/facility director on March 22, 2012 at 4:00 p.m.
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Plan of Correction
By April 20 project director will create Treatment Discharge Notice for those clients being terminated involuntarily. Notice will include reason for discharge. At treatment meeting on April 23 project director will review with counselors procedure to send discharge notice. By April 25 counselors will begin using discharge notice with clients who are involuntarily discharged. During project director's discharge review of client files, project director will insure involuntary discharge notice is in file. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to inform the client, that they have the opportunity to request reconsideration of the decision to terminate treatment in three of three client records. The findings include:Seven client records were reviewed on March 22, 2012. Three clients were involuntarily discharged and the facility was required to permit the client the opportunity to request reconsideration of the decision to terminate treatment in client records # 2, 3, and 5. Client # 2 was admitted to the program on March 10, 2011 and was involuntarily terminated from the program on July 25, 2011. There was no documentation in the patient record that indicated that the patient was provided the opportunity to request reconsideration of the decision to terminate treatment. Client # 3 was admitted to the program on May 12, 2011 and was involuntarily terminated from the program on July 28, 2011. There was no documentation in the patient record that indicated that the patient was provided the opportunity to request reconsideration of the decision to terminate treatment. Client # 5 was admitted to the program on February 14, 2011 and was involuntarily discharged on June 17, 2011. There was no documentation in the patient record that indicated that the patient was provided the opportunity to request reconsideration of the decision to terminate treatment. The finding was confirmed by the project/facility director on March 22, 2012 at 4:00 p.m.
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Plan of Correction
By April 20 project director will create Treatment Discharge Notice for those clients being terminated involuntarily. Notice will include the opportunity to request reconsideration of the decision to terminate treatment. At treatment meeting on April 23 project director will review with counselors the Treatment Discharge Notice containing reconsideration request. By April 25 counselors will begin using new discharge notice for clients who are involuntarily discharged. During project director's discharge review of client files, project director will insure discharge notice contains request for reconsideration. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of client records, the facility failed to document that the individual treatment and rehabilitation plan was developed with the client in four of six records reviewed. The findings include:Eight client records were reviewed on March 22, 2012. Six client records were reviewed for individual treatment and rehabilitation plans developed with the client. A review of client records # 1, 4, 5 and 7 revealed that it could not be determined if the treatment plan was developed with the clients. In these records, there is no documentation that the client signed off on the treatment and rehabilitation plan. Further, facility staff failed to document in the progress notes that the treatment plan was developed with the client. Counselor # 2 was interviewed and asked how staff documented that the treatment plan was developed with the client. The counselor explained that they only have the client sign off on the treatment plan if it is required for funding purposes. The finding was also reviewed with the project/facility director and was not disputed.
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Plan of Correction
Treatment plan form was revised by project director to include client signature indicating client was involved with development of treatment plan. Project director has discussed with counselors their responsibility to obtain client signatures when developing initial treatment plan and all treatment updates. Treatment plans written beginning April 23 will have client signatures. Project director will monitor for client signature when reviewing client file during initial file review and at each update review. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the staffing requirements facility summary report and active client list, the facility failed to notify the Department of a change in authorized maximum capacity.The findings include:The staffing requirements facility summary report was reviewed on March 22, 2012. The summary report, signed by the Project/Facility Director, indicated the facility had 93 current clients. The facility is licensed by the Division for a maximum client capacity of 91.The Facility Director generated an active client list on March 22, 2012. The active client list had 93 active clients. The Facility Director acknowledged that the facility was currently over the authorized client capacity of 91.
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Plan of Correction
Project director sent letter to Division of Licensure dated March 22 requesting increase in maximum client capacity. Approval letter was received March 28 along with revised license certificate for maximum capacity of 98 clients. Project director will review client capacity on a weekly basis beginning April 23 to insure maintaining appropriate client capacity. |