INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 18, 20110 through January 20, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northwestern Human Services of Delaware County, 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 and a plan of correction is due on February 22, 2011.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, staff development records and an interview with the facility director, the facility failed to document 25 hours of annual training required for counselors in five of six files reviewed for the training year July 1, 2009 through June 30, 2010.
The findings include:
Six counselor personnel and staff development records were reviewed on January 18, and January 19, 2011. Six counselors based on the date of hire were required to complete and verify 25 hours of annual training. The facility failed to document 25 hours of annual training in personnel records # 1, 2, 4, 5 and 6 as defined in the staffing requirements facility summary report completed and reviewed on January 18, 2011.
Employee # 1 was hired on May 19, 2008. The facility training year is from July through June. Employee # 1 completed 16 hours of annual training from July 2009 through June 2010.
Employee # 2 was hired on May 19, 2008. The facility training year is from July through June. Employee # 2 completed 6 hours of annual training from July 2009 through June 2010.
Employee # 4 was hired on October 1, 2007 The facility training year is from July through June. Employee # 4 completed 4 hours of annual training from July 2009 through June 2010.
Employee #5 was hired on May 16, 2000. The facility training year is from July through June. Employee # 5 completed 10 hours of annual training from July 2009 through June 2010.
Employee #6 was hired on March 10, 2008. The facility training year is from July through June. Employee # 6 completed 8 hours of annual training from July 2009 through June 2010.
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Plan of Correction
The facility supervisor will begin to track and monitor the training hours earned by each clinician to avoid this in the future. This will be done on a tracking grid which will be monitored by supervisor. |
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 January 18, 2010, and an interview with the facility director, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
On January 18, 2011 and January 19, 2011 the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed eight counselors, a clinical supervisor, project director and facility director as clinical staff. The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based on the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week 40, and the total number of clients assigned to the following employees on January 18, 2011 and January 19, 2011, employees # 3 and 4 exceeded the allowable maximum caseload of 35:1.
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 facility's standard workweek.
The number of hours per week devoted by Employee # 3 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 15 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee #3 had 25 active clients on January 18, 2011 and January 19, 2011. Employee #3 had a caseload of 67:1 (15/40 = .375 FTE 25 clients/.375 FTE = 67:1 caseload).
The number of hours per week devoted by Employee # 4 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 25 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 3 had 31 active clients on January 18, 2011 and January 19, 2011. Employee # 4 had a caseload of 50:1 (25/40 = .625 FTE 31 clients/.625 = 50:1 caseload).
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Plan of Correction
Clients will be moved off of the caseloads of the two individuals referenced to bring the ratio down to 35:1. Going forward, Caseloads will be monitored daily by the facility supervisor to ensure that the client to staff ratio does not exceed 35:1. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill logs and an interview with the project/facility director, the facility failed to document whether the fire alarm and smoke detector system was operative for three of three fire drills conducted since the follow up survey of October 2010.
The findings include:
Fire drill logs were reviewed on January 18, 2011 for the months of October, November and December 2010. Regulations require the nonresidential facility shall maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative. The facility failed to document whether the fire and smoke detector system was operative for the fire drills in October, November and December 2010.
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Plan of Correction
The staff that conduct the monthly fire drills in the building have been instructed to always activate the fire alarm system to conduct firedrills and to never conduct verbal fire drills. This will be incorporated into the firedrill policy for the Sharon Hill facility. In the event that a fire alarm cannot be activated, it must be documented by the staff conducting the drill that the system was tested and operaple at the time of the drill. Program director will monitor and supervise the monthly fire drills. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant tour, the facility failed to display the hours of operation.
The findings include:
A physical plant inspection was conducted on January 18, 19 and 20, 2011. Hours of operation shall be displayed in an area visible to the general public. The facility did not display the hours of operation.
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Plan of Correction
The facility hours have already been posted in a public place(the window). Additionally, the hours of operation will be framed and posted by the program supervisor in a place where it cannot be removed in the future. Program supervisor will conduct monthly check ups to ensure that the hours of operation are always posted in a public place. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to display an emergency telephone number in an area visible to the general public.
The findings include:
A physical plant inspection was conducted on January 18, 19 and 20, 2011. An emergency telephone number posted in an area visible to the general public is required at all outpatient treatment programs. The facility did not display an emergency telephone number.
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Plan of Correction
The emergency telephone number has recently been posted in a public place (the window) by the program supervisor. It will be framed and posted in a place that it cannot be removed. Additionally, the program supervisor will conduct monthly checks to ensure the hours of operation are still posted in a publice place continually. |