INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 27, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Genesis House Inc. Bloomsburg, 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 and a plan of correction is due on February 20, 2010.
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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 summary report provided by the facility on January 27, 2010 and a discussion with the Project Director and Facility Director on January 27, 2010, the facility failed to ensure that staff to client ratios remained at or under 35:1.
The findings included:
Four counselors caseloads were reviewed on January 27, 2010. Based on the number of hours the employee worked at this facility, and the number of clients on the counselors' caseload, one counselor exceeded the caseload of 35:1. The counselors represented by personnel records # 1, 3 and 4 had caseloads under 35:1. The counselor represented by personnel record #2 had a caseload of 37:1, which exceeded the maximum of 35:1.
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Plan of Correction
Project director will meet with the facility director on 2/10/10 to develop and implement a plan of action to adjust the staff to client ratios of the facility to meet the standard.
Facility director will review the staff to client ratios of the facility with the project director on a weekly basis by 2/26/10 to ensure consistent compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records and an interview with the Project Director and the Facility Director, the facility failed to document treatment plan reviews and updates within sixty days, in two of three client records.
The findings include:
Six client records were reviewed on January 27, 2010. Three client records required treatment plan review and updates. In accordance with the facility policy, treatment plan reviews and updates are required to be completed every sixty days. The facility failed to document treatment plan review and updates within sixty days, in client records #2 and 4.
In client record # 2, the client was admitted on April 7, 2009. The comprehensive treatment plan was completed on May 19, 2009. The first treatment plan update was due no later than July 19, 2009 and was not completed until August 3, 2009.
In client record # 4, the client was admitted on May 20, 2009. The comprehensive treatment plan was completed on June 23, 2009. The first treatment plan update was due no later than August 23, 2009. There was no record of an update in the client record.
A discussion with the Project Director and the Facility Director on January 27, 2010 confirmed that the treatment plan updates were not completed within the 60 day timeframe.
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Plan of Correction
Project director will retrain the facility staff on the appropriate completion of the facility's treatment plan updates on 2/10/10.
Facility director will monitor by conducting client chart reviews on a weekly basis with a focus on ensuring compliance with all facility policies to ensure compliance by 2/26/10. |