INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 24-25, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Dolminis 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of nine personnel and training records on October 24-25, 2017, the facility failed to make sure all staff were trained for 6 hours in HIV/AIDS in the required time frame. Counselors shall complete the training within the first year of employment. Six personnel records which required documentation of the mandatory communicable disease training were reviewed. The facility failed to provide documentation of HIV/AIDS training for Employee #6.Employee #6 was hired October 3, 2016 as a counselor. This employee was required to obtain six hours of HIV/AIDS training by October 3, 2017. Employee #6 failed to obtain the training as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor who did not receive HIV training is scheduled to attend HIV training on 12/21/2017.
All staff are responsible to monitor and attend needed trainings by due dates.
Clinical supervisor will review counselors training needs and assure that counselor is signed up for and attends mandated trainings on or before due date
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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 September 7, 2017, and during final review of the the licensing inspection of October 24-25, 2017, the facility failed to ensure that staff caseloads remained at or under 35:1.Employee #6 was hired as a counselor on October 3, 2016. He works 40 hours per week at the facility and has a caseload of 41 active drug and alcohol patients. Employee #6 40 hrs/35= 1.142 FTE Calculation 41 = 35.9019 or 36:1Employee #6 has an FTE caseload of 36:1.
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Plan of Correction
Counselor was over FTE caseload by 1 client.
1 client has been reassigned to another counselor
All counselors are within or below the 35:1 ratio and will remain in the 35:1 counselor client ratio.
Client staff ratio will be monitored according to census by clinical supervisor, AA and program director ongoing.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of patient records on October 24-25, 2017, the facility failed to document a completed treatment plan update at least every 60 days in two of eight client records reviewed. Patient #4 was admitted on April 25, 2017. A comprehensive treatment plan was completed for the client on May 25, 2017. The treatment plan update was due on July 25, 2017, but was completed on September 22, 2017.Patient #5 was admitted on February 29, 2017. The last two treatment plan updates were completed on August 1, 2017 and September 19, 2017, but neither treatment plan was signed by the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors are still learning to navigate the new electronic healthcare record that was recently implemented.
Counselor has been alerted to the issue and all counselors were retrained on signature process on 11/7/17.
Clinical supervisor will monitor for counselor signatures in EHRS weekly.
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