INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 7, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Glenbeigh Center of Erie 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
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on August 29, 2016. The form listed three counselors, and a 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. However, the facility caseloads are calculated using a standard 35 hour work week.Based on the total number of hours per week that employee # 4 devoted to clients and the standard work week of 35 hours, employee # 4 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 work week.The number of hours per week devoted by Employee # 4 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 10 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee #4 had 21 active clients on August 29, 2016.Employee # 4 10/35 = .285 FTE 21 clients/.285 FTE = 74:1 caseloadThe findings were discussed with the facility director.
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Plan of Correction
After being explained the formula to correctly figure out proper caseload,clients were removed from employee #4's clinical caseload and added to the caseload of other clinical staff at the facility with the utmost respect to each client's clinical needs. Going forward no employees shall carry a clinical caseload that exceeds the numbers detailed in the staffing requirements. The Project Director will be informed of any issues surrounding under-staffing of caseloads by the Office Coordinator. The Project director will also routinely check case load numbers to ensure that facility caseloads are in compliance with regulations. |
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.
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Observations
Eight client records were reviewed on September 7, 2016 for informed and voluntary consent forms. One out of eight client records contained documentation that the facility released information to a family member after the consent had expired.Client record #8 contained a consent form that was signed and dated May 17, 2016 and expired on May 17, 2016 for a family member. The facility continued to release information to the family member without an updated consent to release information form. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The electronic medical record was updated to ensure that all releases of information expire one year after a client discharges from our facility unless other wise specified by the client. Releases of information will automatically become revoked after the year. The facility corrected the deficiency by implementing the new releases of information in the medical record through our IT department. The Project director followed through to ensure that the new release of information was implemented. This is a permanent fix to the deficiency. The Project director will be emailed if any further changes are made to the release of information and will make sure that any new changes do not cause the deficiency to occur again. |