INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on March 30, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Livengrin Foundation, Inc. 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
Based on the review of personnel records, the facility failed to provide documentation that an individual training plan, for the current training year, was appropriate to the employee's skill level in one of nine applicable personnel records reviewed. Additionally, the facility failed to provide documentation that an individual training plan was completed for the current training year in one of ten personnel records reviewed.
Employee # 2 was hired as the Facility Director on September 10, 2018. The individual training plan, signed by the employee and supervisor on December 18, 2019 only listed CPR training.
Employee # 5 was hired as a counselor on October 10, 2016. There was no documentation of an individual training plan for the current year, which was identified as July 1, 2019 to June 30, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Individual training plans will be completed on an annual basis. Human Resources will create a comprehensive training plan that will be shared with supervisors in June of each year. Supervisors will collaborate with each employee to develop their training plan. Human Resources will ensure that all training plans are completed and returned by June 30th of each year for the following fiscal year.
Training plans for employees 2 and 5 have been updated.
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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 submitted to the Department, the facility failed to ensure that three counselors did not exceed the outpatient 35 to 1 counselor to client ratio. Additionally, the facility failed to ensure that the overall facility FTE counselor caseload did not exceed 35 to 1.
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 December 12, 2016. The ratio calculation was as follows: 40/40 = 1(FTE); 52/1 = 52, which equals to a client/counselor ratio of 52:1.
Employee # 6 was hired as a counselor on August 1, 2016. The ratio calculation was as follows: 40/40 = 1(FTE); 45/1 = 45, which equals to a client/counselor ratio of 45:1.
Employee # 8 was hired as a counselor on February 18, 2008. The ratio calculation was as follows: 40/40 = 1(FTE); 48/1 = 48, which equals to a client/counselor ratio of 48:1.
The facility's overall client to counselor ratio calculation was as follows: 235/40 = 5.875 (FTE); 221/5.875 = 37.6=38:1
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Current census is 199 patients with 6 counselors at 40 hours each devoted to outpatient and general outpatient levels of care. Each of the counselors carries a current caseload of 33, with the exception of one counselor carrying a caseload of 34.
Director of Outpatient Services has posted an open position for counseling staff. An assessment counselor, meeting DDAP requirements of the counseling role, has been hired and will carry a caseload should the census increase.
Director of Outpatient Services will monitor the census of each of the sites and move outpatient counseling staff as needed to accommodate census at each of the sites. |