INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18-19, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alliance Medical 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 and a plan of correction is due on October 20, 2008.
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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 the calculation of the client to counselor ratio on 9-19-08, the facility failed to maintain individual caseloads at or below 35:1.Finding: The client to counselor caseload was at 36/1.
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Plan of Correction
The counselor to client was at 36/1 instead of the required 35/1. A vacancy within the counseling staff has resulted in the caseload ratio issue. The vacancy will be filled by an appropriate candidate selected from resumes sent as a result of advertising in the Pittsburgh Post Gazette.
Counselors will be temporarily assigned extra cases until the position is filled. Finally, an exception will be filed to cover a similar situation in the future. The Facility Director is responsible for filling the vacant position and for filing the exception. |
709.93(a) 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:
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Observations
Based on a review of nine patient records on 9-18-08 and 9-19-08, the facility failed to post accurate dates on patient documentation. Finding: The facility failed to post accurate dates for follow-up documentation in one client record, #6. The record was reviewed on 9-19-08. There was a completed follow-up form and also a progress note documenting that the follow-up was done. Both the follow up form and the progress note were dated as completed on 10-1-08.
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Plan of Correction
The facility did not post accurate dates for follow-up documentation in the client record. The documented date was not accurate and indicated that the follow-up was completed on 10/1/2008. The clinical supervisor will provide training in proper documentation of both dating and completion of follow-up information. The clinical supervisor will be responsible for ongoing compliance with this regulation through on going supervision and regular record review of closed cases. |