INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 23, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Resources for Human Development was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of personnel records, the facility failed to document feedback forms in five of nine records reviewed.
The findings include:
Nine personnel records were reviewed on May 23, 2014. Five personnel records were reviewed for feedback forms. The training year reviewed was July 1, 2012 - June 30, 2013. The following employee records lacked forms after training's, #2, 3, 4, 6 and 7.
A discussion with the facility director took place on May 23, 2014 and he confirmed the findings.
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Plan of Correction
Training feedback forms will be completed by the attendee following the training they participate in. They will be completed within the 5 working days following the date of training. The Director will be tasked with ensuring compliance of this policy. This will begin on June 23rd. |
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 4/1/14, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on 4/1/14. The form listed seven counselors, one clinical supervisor 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 4/1/14 employees # 5 and 9 exceeded the allowable maximum 35:1 caseload.
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.
Employee # 5 was hired as a counselor on January 6, 2014. The number of hours per week devoted to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 2 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that employee #5 had 3 active clients. Based on this information, the calculation resulted in a caseload of 53:1.
Employee # 9 was hired as a counselor on July 31, 2012. The number of hours per week devoted to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 4 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that employee #9 had 9 active clients. Based on this information, the calculation resulted in a caseload of 79:1.
An interview with the facility director took place on May 23, 2014 and he confirmed the findings.
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Plan of Correction
Counselors at Rise Above will be held to the standard of 35:1 client ratio. This standard will be monitored ongoing by the Assistant Director and the Director to ensure compliance. This will begin on June 23rd.
With regard to Employee's #5 & #6, they have increased the amount of hours available onsite to accomodate the needed ratio as presented in the standards. This change took place on 6/10/14 and was overseen by the Director. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consents in eight of ten records reviewed.
The findings include:
Ten client records were reviewed on May 23, 2014. The facility failed to document informed and voluntary consents in eight client records, specifically records, #1, 2, 3, 5, 6, 7, 8 and 10.
Client record #1 - contained a consent to release information form dated 10/23/13 to a government agency that did not have the date the client signed the consent form. Additionally, a consent to release information form dated 12/18/13 to a treatment facility did not have the date the witness signed the consent.
Client record #2 contained consent to release information forms dated 11/20/13 to the client's parole officer, emergency contact and funding source that did not have the date the witness signed the consent forms.
Client record #3 contained a consent to release information form dated 12/19/13 to the client's emergency contact did not have t the date the witness signed the consent. Additionally, a consent to release form dated 12/19/13 to the client's parole officer did not have what was being released and the purpose for the release when other was checked on the consent form.
Client record #5 contained a consent to release information form dated 1/8/14 to the client's emergency contact that did not have the date the witness signed the consent.
Client record #6 contained a consent to release information form dated 8/7/13 to the client's emergency contact that did not have what was being released and the purpose for the release. Additionally, there was a letter sent out with no date addressed "to whom it may concern."
Client record #7 contained a consent to release information form dated 12/18/13 to the client's parole officer that did not have what was being released, the purpose for the release or the date the client signed the consent.
Client record #8 contained a consent to release information form dated 9/25/13 to the client's parole officer that did not have the date the client signed the consent. Additionally, a letter was sent out with no date addressed "to whom it may concern."
Client record #10 contained a consent to release information form dated 11/15/13 to the client's parole officer that did not have the date the client signed the consent. Additionally, a letter was sent out with no date addressed "to whom it may concern."
A discussion with the facility director took place on May 23, 2014 and he confirmed the findings.
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Plan of Correction
All releases of information will list what specific information is to be released. If the category "other" is indicated, it will include a written description of the information to be released. Releases will be signed and dated by the client and a witness. All letters/correspondence will be addressed to a specific individual and/or organization and not include the designation "To Whom It May Concern." Compliance with these policies will be ensured by the Assistant Director and Director monitoring client information on an ongoing basis. This will begin on June 23rd. |