INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 25, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services Carlisle 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 March 17, 2010.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the " Staffing Requirements Facility Summary Reports " for all of the facilities in the Project and interviews with the Project ' s administrative staff, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.
The findings include:
The " Staffing Requirements Facility Summary Reports " for the nine facilities that make up the project list a total of 59 counselors and/or counselor assistants who are fee-for-service employees and/or full- or part-time employees. The total of the hours per week provided to the project by counselors and/or counselor assistants equates to 30.69 FTE counselor and/or counselor assistant positions within the project.
The " Staffing Requirements Facility Summary Reports " for each of the nine facilities within the project revealed that no employees were listed as full-time clinical supervisors. A full-time equivalency of 30.69 counselors and/or counselor assistants requires a minimum of 3 full-time clinical supervisors within the project.
The Executive Director is listed as the Project Director (designated as employee # 1 for facility number 367070) and as the Facility Director for facility numbers 227059, 387012, and 677044 and cannot also act as a full-time clinical supervisor. The person listed as the Facility Director for facility numbers 067079, 217049, 017068, 367070 and 067058 (designated as employee # 2 for facility number 367070) cannot also act as a full-time clinical supervisor. The person listed as the Facility Director and clinical supervisor for facility number 387019 (designated as employee # 2 for facility number 387019) cannot also act as a full-time clinical supervisor.
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Plan of Correction
Pennsylvania Counseling Services submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State laws relating to drug and alcohol
treatment. This Plan of Correction should not be construed as either a
waiver of the facility's right to appeal or an admission of past or
ongoing violations of applicable regulatory requirements.
The Vice President of Quality Improvement and Director of Quality Improvement will ensure that there is one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors and/or counselor assistants in the entire Project. The Vice President of Quality Improvement and Director of Quality Improvement will ensure that these supervisors meet DOH staffing regulations for the position of full-time Clinical Supervisor. The Vice President of Quality Improvement and Director of Quality Improvement will also ensure that the Staffing Requirement Facility Summary Reports are completed accurately to reflect these supervisory hours for future inspections.
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up attempts in one of two discharge records reviewed.
The findings include:
Four client records were reviewed on February 25, 2010. Two of the four client records were required to document follow-up attempts. In accordance with the facility's policy and procedure manual it stated that follow-up would be made within 90 days of discharge date and will be documented in records. Follow up was not documented in one of two required client records.
Record # 4 was admitted on 10/20/09 and discharged on 11/20/09. The follow up attempt was due by 2/20/10.
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Plan of Correction
The QI Department will oversee that facility staff are re-educated to send the follow-up questionnaire to all clients within 90 days of the discharge date. Staff will be instructed to send the follow-up questionnaire to the client's last known address for those situations in which the client has relocated and the new address in not known. The QI Department will ensure compliance with the facility's procedure through ongoing chart reviews. |