INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 9-10, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Addiction and Behavioral Counseling Associates 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
The facility failed to ensure that outpatient staff caseloads remain at or under 35:1.
Based on the total number of hours per week devoted to clients, and the facility's standard work week of 40 hours, employees # 5, 7, and 8 exceeded the allowable maximum 35:1 caseload.
As reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 5 to outpatient client treatment was 10 hours per week. The employee had 10 active clients at the time of the inspection.
The caseload calculation is as follows- 10/40 = .25 FTE --- 10 clients/.25 FTE = 40/1 caseload.
As reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 7 to outpatient client treatment was 25 hours per week. The employee had 25 active clients at the time of the inspection.
The caseload calculation is as follows- (25/40 = .625 FTE --- 26 clients/.625 FTE = 40/1 caseload.
As reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 8 to outpatient client treatment was 15 hours per week. The employee had 14 active clients at the time of the inspection.
The caseload calculation is as follows- (15/40 = .375 FTE --- 14 clients/.375 FTE = 38/1 caseload.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will monitor the caseloads of the counselors and assure that they are not out of compliance with the identified ratio. For counselors that were out of ratio at the time of the audit, the caseloads were reviewed. There were cases that were closed, and caseload reassignment was also completed. As necessary, additional staff may be hired to take on additional cases. The facility will be in compliance by 9/16/2019. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The facility failed to obtain the services of a CPA to complete an annual financial audit for the years of 2017 and 2018.
The facility has documentation of an exception to the annual financial audit; however, that exception is only valid providing that the annual gross revenue remains under $500,000. Per 2017 and 2018 tax documentation, the annual gross revenue exceeded $500,000 for 2017 and 2018. The facility was required to have an independent CPA complete an annual financial audit for 2017 and 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will be responsible to ensure that the annual audit of financial activities is completed. The Project Director will obtain an independent CPA by the completion of the fiscal year to conduct the annual financial audit. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
The facility failed to develop and maintain a data collection and record keeping system that allows for the efficient retrieval of data and for the identification of clients' admissions and discharges within a specific time period.
Client record lists were provided to the licensing specialist during the onsite inspection, September 9-10, 2019. The lists provided did not include admission and discharge dates, which made it difficult to select client records that met the criteria for the licensing period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor was in communication with the provider of the Electronic Records Management System. As of 9/23/19 the facility was able to generate a report through the Electronic Records Management System to include admission and discharge dates. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
The facility failed to report an unusual incident regarding a client death.
Client records were reviewed on September 10, 2019. Through record review, it was discovered that client #5, admitted on February 18, 2019 had passed away. Client #5 was then discharged on April 21, 2019. There was no documentation of an unusual incident report being sent to DDAP within 3 business days, as required.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director or designee will notify DDAP within 3 days of any unusual incident including all client deaths, regardless of circumstance. This process was implemented on 9/10/2019. |
709.93(a)(6) LICENSURE Client records
709.93. 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:
(6) Individual treatment and rehabilitation plan.
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Observations
The facility failed to document case consultation notes in client records #3, 4 and 6.
Client #3 was admitted on May 18, 2018. There were no case consultation notes documented in client record #3.
Client #4 was admitted on January 13, 2019 and discharged on June 27, 2019. There were no case consultation notes documented in client record #4.
Client #6 was admitted on November 27, 2018 and discharged on March 28, 2019. There were no case consultation notes documented in client record #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Primary Counselor and the Clinical Supervisor will coordinate case consults on all clients after 180 days of continuous treatment in the program. Cases will be reviewed every 180 days in the program. This process will be implemented by 10/1/2019. |