INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on October 23-24, 2019 Based on the findings of the on-site inspection, Catholic Charities Diocese of Harrisburg , PA, Inc was found to not 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)(3)(i) LICENSURE NonHosp Rehab
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.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
The facility failed to have one FTE counselor for every eight clients.
On the Staffing Requirements Facility Summary Report form (SRSFR), staff #2 that was hired on July 8, 2002 as the Facility Director indicated that she was also employed in the role of clinical supervisor and counselor as needed. On the SRSFR, staff #2 reported that she worked 40 hours per week in the role of counselor and 20 hours per week in the role of administration. However, the four-week time period of schedules given to the Department of Drug and Alcohol Programs does not verify 60 hours worked by staff #2. For the week of September 14, 2019, Staff #2 worked 36 hours. For the week of September 21, 2019, Staff #2 worked 28 hours and had 2 days of vacation on September 26th and September 27th, 2019. For the week of September 28, 2019, Staff #2 worked 37.5 hours with September 30th and October 1st, 2019 as vacation days. For the week of October 5, 2019, Staff #2 worked 43.5 hours with October 7th, 2019 as a vacation day.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will enforce the plan of hiring a Counselor or Counselor Assistant by January 31, 2020. The PD and other administration will actively recruit through advertisement and targeted marketing in order to attract more applicants to hire. By hiring a fulltime counselor, the ratio will then meet state regulations. In the future when a counselor resigns or is terminated the PD will begin referring current clients to other comparable residential facilities. Recently, several clients have been discharged. The census is 12 clients. One counselor has 8 clients. The PD has an active caseload of 4 clients. 20 hours of her 40 hour work week is direct clinical and 20 hours is administration. Census will remain in compliance until a fulltime counselor is hired. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
During a review of client records on October 23-24, 2019, the project failed to notify clients in seven out of seven records, that they shall retain civil rights and liberties under section 7 of the act (71 P. S. except as provided by the statute.
Client #1 was admitted on May 28, 2019 and was still current at the time of the inspection. Client #1 was not notified that they may not be deprived of a civil right solely by reason of treatment.
Client #2 was admitted on May 30, 2019 and was still current at the time of the inspection. Client #2 was not notified that they may not be deprived of a civil right solely by the reason of treatment.
Client #3 was admitted on August 20, 2019 and was still current at the time of the inspection. Client #3 was not notified that they may not be deprived of a civil right solely by the reason of treatment.
Client #4 was admitted on October 19., 2018 and was discharged on February 15, 2019. Client #4 was not notified that they may not be deprived of a civil right solely by the reason of treatment.
Client #5 was admitted on November 21, 2019 and was discharged on April 22, 2019. Client #5 was not notified that they may not be deprived of a civil right solely by the reason of treatment.
Client #6 was admitted on December 7, 2018 and was discharged on April 3, 2019. Client #6 was not notified that they may not be deprived of a civil right solely by the reason of treatment.
Client #7 was admitted on July 12, 2019 and was discharged on 8/23/19. Client #7 was not notified that they may not be deprived of a civil right solely by the reason of treatment.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will enforce the plan of correction including updating the proper wording in the policy and handbook indicating that clients shall retain civil rights and liberties under section 7 of the act 71 P. S. except as provided by the statute. The specific wording will include "clients may not be deprived of a civil right solely by the reason of treatment." These documents will be updated by December 15, 2019. The new policy will be reviewed and shared with staff at staff meeting December 18, 2019 and with clients December 19 at house meeting.
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709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
During a review of client records on October 23-24, 2019, the project failed to notify clients of all their civil rights in seven out of seven records.
Client #1 was admitted on May 28, 2019 and was still current at the time of the inspection. Client #1 was not notified that the project may not discriminate on the basis of sex.
Client #2 was admitted on May 30, 2019 and was still current at the time of the inspection. Client #2 was not notified that the project may not discriminate on the basis of sex.
Client #3 was admitted on August 20, 2019 and was still current at the time of the inspection. Client #3 was not notified that the project may not discriminate on the basis of sex.
Client #4 was admitted on October 19., 2018 and was discharged on February 15, 2019. Client #4 was not notified that the project may not discriminate on the basis of sex.
Client #5 was admitted on November 21, 2019 and was discharged on April 22, 2019. Client #5 was not notified that the project may not discriminate on the basis of sex.
Client #6 was admitted on December 7, 2018 and was discharged on April 3, 2019. Client #6 was not notified that the project may not discriminate on the basis of sex.
Client #7 was admitted on July 12, 2019 and was discharged on 8/23/19. Client #7 was not notified that the project may not discriminate on the basis of sex.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will ensure the plan of correction including updating the policy to properly notify clients of all their civil rights. The policy will include the specific wording "The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion." This policy will be updated by December 15. It will be reviewed with staff at staff meeting December 18 and shared with clients December 19 at house meeting. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
The facility failed to include reporting mechanisms to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
The facility's incident report policy failed to include that the facility will ensure reporting of an unusual incident report to an entity is in compliance with State and Federal confidentiality laws.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure the policy is updated by including the wording "the facility will ensure reporting of an unusual incident report to an entity is in compliance with State and Federal confidentiality laws." The program will ensure the receiving entity is knowledgeable and accountable for state and federal laws by accompany each incident report with a cover page that defines state and federal confidentiality laws. This policy will be updated by December 15. It will be shared with staff at staff meeting on December 18.
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