INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 3, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Caring Healthcare Network LLC 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 the 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 #1 was hired as a project director on June 6, 2022 and was still acting in that position. Employee #1 was reported to have10 hours per week devoted to their 9 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 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: 10/40 = .25(FTE); 9/.25= 36, which equals to a client/counselor ratio of 36:1.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The MAT Project Director will reassign clients currently on caseload to recently hired counseling staff to comply with the counselor Full Time Equivalent (FTE). The project director is responsible for the overall management of the project and staff. Therefore the project director will carry a minimal caseload for the sole purpose of maintaining clinical skill that will be no more than 5 clients. This will decrease the time per week devoted to the clients on her caseload. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from February 2023- December 2023, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the months of April and June 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The MAT Project Director will collaborate with the Practice Manager and Nursing Supervisor to ensure that unannounced fire drills are conducted at least once per month. The facility will use an Unannounced Monthly Fire Evaluation Checklist to document monthly fire drills at the facility. Documentation of unannounced fire drills will be filed in a binder and kept in the office of the MAT Project Director. |
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 February 2023 - December 2023 fire drill logs during the inspection, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill.
This finding was reviewed with facility staff during the licensing process
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Plan of Correction
The MAT Project Director will submit an exception request to DDAP requesting not to set off a fire alarm in exchange for yelling fire or utlizing the 4545 paging system when announcing the fire drill. The Progect Director will collaborate with the Practice Manager to include documentation of whether the 4545 paging system or yelling fire was utilized during the time of the drill. The facility will use an Unannounced Monthly Fire Evaluation Checklist to document monthly fire drills at the facility. Documentation of unannounced fire drills will be filed in a binder and kept in the office of the MAT Project Director. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the February 2023 - December 2023 fire drill logs during the inspection, the facility failed to document whether the fire alarm or smoke detector was set off during each fire drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The MAT Project Director will collaborate with the Practice Manager to include documentation of whether a fire alarm, smoke detector, the 4545 paging system or yelling fire was utilized during the time of the drill. The MAT Project Director will submit an exception request to DDAP requesting not to set off a fire alarm in exchange for yelling fire or utlizing the 4545 paging system when announcing the fire drill. |
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
Based on a review of administrative documents and an interview with the project director, the project failed to document an annual financial audit for the fiscal year ending December 31, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The MAT Project Director will submit an exception request to DDAP requesting an exception to the annual financial audit of activities associated with the project ' s drug/alcohol abuse services to remain compliant with 709.25. Fiscal management. The Exception Request Form was emailed on 11/28/2023 and was emailed again on 1/4/2024. Confirmation of this email was received.
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