INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1-2, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Center for Psychiatric and Chemical Dependency Services 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 form completed by the facility on May 13, 2015, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
The Staffing Requirements Facility Summary Report was completed by facility staff on May 13, 2015. The onsite inspection for this facility was conducted on June 1-2, 2015. The document was reviewed both prior to and during the onsite inspection. The form listed ten counselors, two clinical supervisors, project director and facility director as clinical staff .The standard work week was 35 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 standard work week (35) and the total number of clients assigned to the following employees on June 1-2, 2015 employee # 11 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.
The number of hours per week devoted by Employee # 11 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 40 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee #3 had a total of 43 clients, 41 of which were considered active.
Employee # 3 - 40/35 = 1.14 FTE 41 clients/ 1.14 FTE = 36:1 caseload
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Under the direction of the Clinical Administrator or her designee, CPCDS will maintain all caseloads at 35:1. Clinicians will provide supervisors their caseload totals during each supervision meeting and the caseload ratio will be documented in supervision notes. Prior to assigning new cases, supervisors will review clinician caseloads to ensure caseload will not exceed 35:1 with a new patient assignment. The requirement for caseloads not to exceed 35:1 will be reviewed with all supervisors and clinicians in staff meeting on 6/16/15. The Program Director will collect caseload information monthly to ensure no clinician caseload exceeds 35:1. Plan of correction is effective 7/15/15. |
711.94 (g) LICENSURE Medical Assistance Provider Agreement
711.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to document a physician signature on the individual treatment plan and updates for medical assistance clients within the time frame established by the Office on Medical Assistance in two of five client records reviewed.
The findings include:
Ten client records were reviewed on June 1-2, 2015. Five of the ten clients reviewed were funded by medical assistance. All five medical assistance client records were required to have a physician signature on the individual treatment plan and updates within the time frame established by the Office on Medical Assistance. Client records #6 and 8 did not include a physician signature on the individual treatment plan and updates within the time frame established by the Office on Medical Assistance.
Client #6 was admitted to treatment on September 2, 2014 and discharged on December 8, 2014. The individual treatment plan developed on September 25, 2014 did not include a physician signature.
Client #8 was admitted to treatment on August 27, 2014 and discharged on December 12, 2014. The individual treatment plan developed on September 2, 2014 did not include a physician signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Under the direction of the Clinical Administrator or her designee CPCDS will ensure that all treatment plans are signed by the physician. Physicians will receive electronic reminders that treatment plans are due for review and signature. Supervisors will review all treatment plans weekly and will provide a monthly report to the Program Director indicating that treatment plans have been signed within 2 weeks of the review. Program Director will notify physicians and their immediate supervisor of any treatment plans not signed within 2 weeks and will be directed to sign the plans within 24 hrs. All clinicians will be re-trained on the electronic treatment plan process for adding a physician to the treatment plan by 7/15/15.Plan of correction is effective 7/15/15. |