INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18, 2020 through November 19, 2020 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, Family Service Association of Bucks County 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to provide documentation of an individual training plan, appropriate to that employee's skill level and developed with input from both the employee and the supervisor in two of twelve personnel records reviewed.
Employee # 11 was hired as a counselor on June 12, 2017. The individual training plan was completed on June 26, 2020, but it was not individualized and based on the employee's skill level.
Employee # 12 was hired as a counselor on November 17, 2020. The individual training plan was completed on June 26, 2020, but it was not individualized and based on the employee's skill level.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors and employees will discuss what skill level and develop an individualized plan with each evaluation. Clinical Manager to review for appropriateness to employee's skill level prior to signing.
Employee #11 Clinical Supervisor will discuss with employee what specific educational trainings employee would like to complete and a addendum will be provided to employee's performance review with HR by 01/31/2021.
Employee #12 Clinical Supervisor will discuss with employee what specific educational trainings employee would like to complete and a addendum will be provided to employee's performance review with HR by 01/31/2021. |
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 counselors did not exceed the outpatient 35 to 1 counselor to client ratio as 12 counselors exceeded the 35 to 1 ratio, based on a review of the Staffing Requirement Facility Summary Report.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee #5 was hired as a counselor on August 4, 2020 and was still employed at the time of the inspection. Their ratio calculation was as follows: 35/37.5= .9333 (FTE); 38/.9333= 40.7152, which equals to a client/counselor ratio of 41:1.
Employee #6 was hired as a counselor on August 10, 2020 and was still employed at the time of the inspection. Their ratio calculation was as follows: 30/37.5= .8 (FTE); 38/.8= 47.6 which equals to a client/counselor ratio of 48:1.
Employee #7 was hired as a counselor on January 21, 2020 and was still employed at the time of the inspection. Their ratio calculation was as follows: 20/37.5= .5333 (FTE); 20/.5333= 37.5023 which equals to a client/counselor ratio of 38:1.
Employee #8 was hired as a counselor on September 21, 2020 and was still employed at the time of the inspection. Their ratio calculation was as follows: 30/37.5= .8 (FTE); 47/.8= 58.75 which equals to a client/counselor ratio of 59:1.
Employee #9 was hired as a counselor on September 21, 2020 and was still employed at the time of the inspection. Their ratio calculation was as follows: 30/37.5= .8 (FTE); 47/.8= 58.75 which equals to a client/counselor ratio of 59:1.
Employee #10 was hired as a counselor on August 1, 2018 and was still employed at the time of the inspection. Their ratio calculation was as follows: 28/37.5= .7466 (FTE); 33/.7466= 44.2003 which equals to a client/counselor ratio of 45:1.
Employee #11 was hired as a counselor on June 12, 2017 and was still employed at the time of the inspection. Their ratio calculation was as follows: 10/37.5= .2666 (FTE); 10/.2666=37.5093 which equals to a client/counselor ratio of 38:1.
Employee #13 was hired as a counselor on August 15, 2017 and was still employed at the time of the inspection. Their ratio calculation was as follows: 23/37.5= .6133 (FTE); 23/.6133= 37.5020 which equals to a client/counselor ratio of 38:1.
Employee #14 was hired as a counselor on February 20, 2018 and was still employed at the time of the inspection. Their ratio calculation was as follows: 12/37.5 = .32 (FTE); 12/.32= 37.5 which equals to a client/counselor ratio of 38:1.
Employee #15 was hired as a counselor on February 24, 2020 and was still employed at the time of the inspection. Their ratio calculation was as follows: 7/37.5= .1866 (FTE); 11/.1866-= 58.9496 which equals to a client/counselor ratio of 59:1.
Employee #16 was hired as a counselor on July 29, 2019 and was still employed at the time of the inspection. Their ratio calculation was as follows: 5/37.5= .1333 (FTE); 5/.1333= 37.5093 which equals to a client/counselor ratio of 38:1.
Employee #17 was hired as a counselor on July 29, 2019 and was still employed at the time of the inspection. Their ratio calculation was as follows: 2/37.5= .0533 (FTE); 2/.0533= 37.5234 which equals to a client/counselor ratio of 38:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Manager to hire additional clinicians to lower the current ratios clinical supervisors will review quarterly to ensure that ratio standards are met. The goal will be to decreased by: discharges and transfers by 1/15/2021
Employee # 5 Clinical Supervisor to reduced caseload by discharging and transfer clients when needed
Employee # 6 Clinical Supervisor to reduced caseload by discharging and transfer clients when needed
Employee # 7 Clinical Supervisor to reduced caseload by discharging and transfer clients when needed
Employee # 8 Clinical Supervisor to reduced caseload by discharging and transfer clients when needed
Employee# 9 Clinical Supervisor to reduced caseload by discharging and transfer clients when needed
Employee # 10 Clinical Supervisor to reduced caseload by discharging and transfer clients when needed
Employee # 11 Clinical Supervisor to reduced caseload by discharging and transfer clients when needed
Employee # 12 Clinical Supervisor to reduced caseload by discharging and transfer clients when needed
Employee # 13 Clinical Supervisor to reduced caseload by discharging and transfer clients when needed
Employee # 14 Clinical Supervisor to reduced caseload by discharging and transfer clients when needed
Employee # 15 Clinical Supervisor to reduced caseload by discharging and transfer clients when needed
Employee # 16 Clinical Supervisor to reduced caseload by discharging and transfer clients when needed
Employee # 17 Clinical Supervisor to reduced caseload by discharging and transfer clients when needed |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client #3 was admitted on March 19, 2020 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Manager along with clinical supervisors will provide training on proper completion of release forms by 02/15/2021. Release forms will become an approved service the EMR system. Each clinical supervisor will review for accuracy and have clinician make corrections if needed
Client # 3 Is still active, a new release will be obtained and signed for the funding source by 02/15/2021 |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to ensure that all consent to release information forms included the name of the person, agency, or organization to whom the disclosure was to be made to three of seven client records reviewed.
Client #1 was admitted on March 2, 2020 and was active at the time of inspection. A release of information form was signed and dated by the client on March 2, 2020.
Client #4 was admitted on May 20, 2020 and was discharged on August 30, 2020. A release of information form was completed on May 19, 2020.
Client #6 was admitted on January 13, 2020 and was discharged on September 16, 2020. A release of information form was signed and dated by the client on January 13, 2020.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Manager along with clinical supervisors will provide training on proper completion of release forms by 02/15/2021. Clinical supervisors will monitor monthly by verifying Release of information through Credible report.
Client # 1 is still active, a new release will be obtained by the clinician 02/15/2021
Client # 4 Client has been discharged and new releases will be obtained if client reengages new releases with live signature will be obtained by intake.
Client # 6 Client has been discharged and new releases will be obtained if client reengages new releases with live signature will be obtained by intake. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
The facility failed to ensure that all consent to release information forms included the dated signature of the client four of seven client records reviewed.
Client #1 was admitted on March 2, 2020 and was active at the time of inspection. The release of information forms to the funding source and the parole officer were signed and dated by the witness on March 2, 2020. Additionally, a release of information form to an emergency contact was signed and dated by the witness on June 8, 2020. Also, the release of information form to a primary care physician was signed and dated by the witness on July 26, 2020.
Client #4 was admitted on May 20, 2020 and was discharged on August 30, 2020. The release of information forms to a laboratory, an emergency contact, and a primary care physician were all signed and dated by the witness on May 19, 2020. Additionally, a release of information form to a funding source was signed and dated by the witness on May 20, 2020.
Client #5 was admitted on February 19, 2020 and was discharged on May 26, 2020. A release of information form to an emergency contact was signed and dated by the witness on March 25, 2020.
Client #7 was admitted on March 30, 2020 and was discharged on August 31, 2020. The release of information forms to a primary care physician and an emergency contact were signed and dated by the witness on March 30, 2020. Additionally, a release of information form to a funding source was signed and dated on April 7, 2020. Also, a release of information form to a judge was not signed by the client or witness but was dated on June 23, 2020.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During Covid and with use of virtual services obtaining live signatures has been a challenge. As 10/25/2020 Family Services has started to request clients to come to office for intake and to obtain live signatures. Clinical Manager will work with development team to have consents and releases available on family service website the goal to accomplish this is 02/15/2021
Clinal Manager along with Clinical Supervisors will provide training to intake and clinicians on proper completion of Releases by 02/15/2021
Client # 1 A new release will be obtained for the funding source, PR, emergency contact and PCP by the clinician Mailing releases with a client return self address envelope by 02/15/2021
Client # 4 has been discharged and new releases are unable to be obtained.
Client # 5 has been discharged and new releases are unable to be obtained.
Client # 7 A new release will be obtained for PCP, funding source and County Judge by the clinician
clinician Mailing releases with a client return self address envelope by 02/15/2021 |
709.28 (c) (5) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
The facility failed to ensure that all consent to release information forms included the dated signature of the witness in two of seven client records reviewed.
Client # 3 was admitted on March 19, 2020 and was still active at the time of the inspection. Release of information forms to a probation officer, a clerk of courts, and an attorney were all signed by the client on January 30, 2020; however, all the consent forms were signed by the witness on January 22, 2020, which was prior to the client signing them.
Client #7 was admitted on March 30, 2020 and was discharged on August 31, 2020. A release of information form to a judge was not signed by the client or witness but was dated on June 23, 2020.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Intake and clinicians will obtain Release of information. Clinical Manager along with Clinical Supervisors will provide training to intake and clinicians on the proper completion of release forms by 02/15/2021. Clinical supervisors will monitor monthly by verifying Release of information through Credible report.
Client # 3 A new release for PO, clerk of courts, and attorney will be obtained by clinician mailing release with a client return self addressed stamped envelope by 02/15/2021.
Client # 7 A new release form to a judge will be obtained by clinician mailing release with a client return self addressed stamped envelope by 02/15/2021.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
The facility failed to ensure that there was written acknowledgement documented in the client record notifying the client that they have the right to appeal a decision limiting access to their records to the director in seven of seven client records reviewed.
Client #1 was admitted on March 2, 2020 and was still active at the time of the inspection.
Client #2 was admitted on March 12, 2020 and was still active at the time of the inspection.
Client #3 was admitted on March 19, 2020 and was still active at the time of the inspection.
Client #4 was admitted on May 20, 2020 and was discharged on August 30, 2020.
Client #5 was admitted on February 19, 2020 and was discharged on May 26, 2020.
Client #6 was admitted on January 13, 2020 and was discharged on September 16, 2020.
Client #7 was admitted on March 30, 2020 and was discharged on August 31, 2020.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client Rights have been updated to Outpatient and DUI Welcome Packet to include, client rights to appeal a decision, limiting access to their records
Client # 1 will be given a revised welcome packet by intake and will be asked to sign off on the receipt by 02/15/2021
Client # 2 will be given a revised welcome packet by intake and will be asked to sign off on the receipt by 02/15/2021
Client # 3 will be given a revised welcome packet by intake and will be asked to sign off on the receipt by 02/15/2021
Client # 4 Is discharged and will be given revised welcome packet by intake and will be asked to sign off on the receipt if they return for services
Client # 5 Is discharged and will be given revised welcome packet by intake and will be asked to sign off on the receipt if they return for services
Client # 6 Is discharged and will be given revised welcome packet by intake and will be asked to sign off on the receipt if they return for services.
Client # 7 will be given a revised welcome packet by intake and will be asked to sign off on the receipt by 02/15/2021
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
The facility failed to ensure that there was written acknowledgement documented in the client record notifying the client that they have have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in seven of seven client records reviewed.
Client #1 was admitted on March 2, 2020 and was still active at the time of the inspection.
Client #2 was admitted on March 12, 2020 and was still active at the time of the inspection.
Client #3 was admitted on March 19, 2020 and was still active at the time of the inspection.
Client #4 was admitted on May 20, 2020 and was discharged on August 30, 2020.
Client #5 was admitted on February 19, 2020 and was discharged on May 26, 2020.
Client #6 was admitted on January 13, 2020 and was discharged on September 16, 2020.
Client #7 was admitted on March 30, 2020 and was discharged on August 31, 2020.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client rights were updated to Outpatient and DUI Welcome packet to include the clients right to request a correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Client # 1 will be given a revised welcome packet by intake and will be asked to sign on the receipt form by 02/15/2021
Client # 2 will be given a revised welcome packet by intake and will be asked to sign on the receipt form by 02/15/2021
Client # 3 will be given a revised welcome packet by intake and will be asked to sign on the receipt form by 02/15/2021
Client # 4 will be given a revised welcome packet by intake and will be asked to sign on the receipt form by 02/15/2021
Client # 5 has been discharged will be provided a revised welcome packet by intake if they return for services and will be asked to sign on the receipt form.
Client # 6 has been discharged will be provided a revised welcome packet by intake if they return for services and will be asked to sign on the receipt form.
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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
The facility failed to ensure that all treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of six applicable client records.
Client #3 was admitted on March 19, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was completed on March 19, 2020 with an update due no later than May 19, 2020; however, there was no update completed at the time of the inspection.
Client #4 was admitted on May 20, 2020 and was discharged on August 30, 2020. The comprehensive treatment plan was completed on May 20, 2020 with an update due no later than July 20, 2020; however, there was no update completed prior to discharge.
Client #6 was admitted on January 13, 2020 and was discharged on September 16, 2020. The comprehensive treatment plan was completed on January 14, 2020 with an update due no later than March 14, 2020; however, the update was completed on April 28, 2020. Additionally, a treatment plan update was completed on June 23, 2020 with an update due no later than August 23, 2020; however, there was no update completed prior to discharge.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Each clinician will initiate an excel tickler system with due dates of treatment plans for their caseload by 02/15/2021 Clinical supervisors will monitor and review each month.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
The facility failed to maintain a complete client record on an individual, which is to include case consultation notes, in two of five applicable client records.
Client #3 was admitted on March 19, 2020 and was still active at the time of the inspection. There were no case consultation notes documented the client record at the time of the inspection.
Client #6 was admitted on January 13, 2020 and was discharged on September 16, 2020. There were no case consultation notes documented the client record prior to discharge.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Each Clinician will create a tickler system with excel to include due dates of case consultation notes by 02/15/2021. Clinical supervisors will review monthly. |