INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensure inspection that was conducted on September 22, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site inspection, Kensington Hospital Outpatient Treatment Program, 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 supervisory review:
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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" (SRFSR) for all of the facilities in the Project, 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 SRFSR for the two facilities that make up the project list a total of 9.48 FTE counselor positions within the project.The SRFSR for the two facilities within the project revealed that no employees were listed as a full-time clinical supervisor. The SRFSR listed one part time clinical supervisor who worked 20 hours per week in at the project and had a full caseload.. This finding was confirmed with the project director during the administrative review.
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Plan of Correction
Kensington Hospital hired a new full-time Director of the Kensington Hospital Outpatient Treatment Program effective 11/30/17. The new full-time Director provides the required hours needed for the eight(8) counselors in the Outpatient Treatment Program.
Hospital Administration will continue to monitor to assure the full time Director and the number of counselors meet the State requirements. If the need arises, Administration will hire temporary staff, additional staff or increase the hours of existing staff offering them overtime to ensure compliance with the standards. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to provide documentation of TB/STD training in one of two personnel records reviewed where applicable. The TB/STD training documentation was due by 4-14 -2017. TB/STD training documentation was not available at the time of the September 22, 2017 annual inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Kensington Hospital's new Program Director met with the Program Staff and reminded them they must obtain the State mandated trainings (HIV/AIDS, TB/STD and Confidentiality) Training.
All Counselors will have the mandated trainings completed by 2/29/2018.
Also, the Director will develop a form indicating the employee's hire date and monitor the time frames for any mandatory trainings so that trainings will be completed by the due dates.
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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 September 21, 2017 the facility failed to ensure that staff caseloads remained at or under 35:1.The findings include: 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 the facility's part time clinical supervisor client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 15 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that the clinical supervisor had 16 active clients on September 21, 2017.Clinical supervisor (15/35 = .428 FTE 16 clients/.428 FTE = 38:1 caseload)The findings were discussed with facility staff.
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Plan of Correction
Kensington Hospital hired a full-time Director of the Kensington Hospital Outpatient Treatment Program effective 11/30/17. The part-time Clinical Supervisor mentioned in this deficiency was an interim Clinical Director, as the Director of the Program had recently resigned and the new Director was not hired yet.
The full-time Director does not see clients. Also the part-time Clinical Supervisor (20 hours per week) mentioned in the deficiency had a reduction in her caseload from 16 clients to 1 client.
The new Director will continue to monitor staff caseloads and either hire temporary staff, additional staff, or increase the hours of existing staff offering them overtime to ensure compliance with the standards. |