INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 11, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Squirrel Hill 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 Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.
Employee # 4 was hired as a counselor on February 17, 2020 and was still acting in that position. Employee #4 was reported to have 5 hours per week devoted to their 18 clients on their caseload.
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 work week. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE.
The FTE counselor's caseload calculation is as follows: 5/40=.125(FTE); 18/.125=144, which equals to a client/counselors ratios of 144:1.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All applicable staff will be trained on the Staffing Requirements Facility Summary Report and the Full Time Equivalent (FTE) for outpatient caseloads. This training will take place on December 1, 20222.
The OP Manager and Administrative Assistant will run weekly caseload/census reports. They will use these reports to ensure that the counselors caseloads are within the limits taking into consideration their hours works (average) and client's assigned to them.
Clients will be moved to another counselor if needed.
Audit of census reports and review of FTEs will begin on December 5, 2022 |
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 client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of six applicable records reviewed.
Client #3 was admitted on May 19, 2022 and discharged on August 22, 2022. A treatment plan was completed on June 16, 2022 and the next update was due no later than August 16, 2022; however, there is no documentation of an updated treatment plan in the case record.
Client #4 was admitted on March 21, 2022 and discharged on August 31, 2022. A treatment plan completed on April 6, 2022 and the next update was due no later than June 6, 2022; however, it was completed on June 22, 2022.
Client #6 was admitted on June 28, 2022 and was still active at the time of the inspection. A treatment plan was completed on June 20, 2022 and the next update was due no later than August 20, 2022; however, it was completed on September 12, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical OP Director will immediately re-educate all staff at (Specified OP Location) as to the parameters of required Treatment Plan updates, to ensure all treatment plans are updated in a timely manner.
The OP Manager will monitor treatment plan updates with a monthly audit to review at least 50% of all required treatment plan updates.
The staff will be educated by November 30, 2022 and the treatment plan audit will be implemented December 1, 2022. |
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
Based on the review of client records, the facility failed to document case consultations within the facility's policy and procedures manual timeframe of every 90 days and/or at least once in every level of care in two out of five applicable client records.
Client #2 was admitted on December 30, 2021 and discharged on February 24, 2022. There was no case consultation documented in the client record.
Client #4 was admitted on March 21, 2022 and discharged on August 31, 2022. A case consultation was due on June 21 2022; however, it was not completed until August 31, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The OP Director will immediately re-educate all staff at Squirrel Hill on the licensing standard for Client Records and Case Consults.
The OP Manager will conduct Case Consult meetings once a month. The OP Manager will monitor case consults with a monthly audit to ensure that they are being completed per the licensure standard.
The OP Manager will be educated by November 16, 2022. The clinical team at Squirrel Hill will be educated by November 23, 2022. Case consult meetings will begin by 12/1/2022. Finally, Case consult audits will begin immediately. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of two applicable records reviewed.
Client #3 was admitted on May 19, 2022 and discharged on August 22, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical OP Director will immediately re-educate the OP Manager and Administrative Assistant at Allegheny Valley as to the parameters of the required follow-up regulation.
The OP Manager will monitor the consent for follow-up for all new admissions monthly to ensure that the Administrative Assistant knows which patients have consented for follow-up. The Administrative Assistant will track when the follow-up calls/letters need to be completed per the GRC policy. The OP Manager will conduct a monthly audit to ensure that the follow-up calls/letters are completed.
The OP Manager and Administrative Assistant will be educated by November 30, 2022, and the follow-up consent audit will begin December 1, 2022. The follow-up calls/letters audit will begin January 2, 2023. |