INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 23, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Treatment Trends Inc. Confront 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
A licensing renewal inspection was conducted on May 23, 2018. Based on a review of the finalized Staffing Requirements Facility Summary Report submitted by the facility during the licensing process, the facility failed to ensure that all staff caseloads remain at or under 35:1Based on the total number of hours per week devoted to clients, and the standard work week of 35 hours, employees # 8 and 10 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 standard work week of 35 hours. reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 8 to outpatient client treatment was 20 hours per week. The employee had 24 active clients as of May 16, 2018. - Employee # 8 (20/35 = .5714 FTE *** 24 clients/.5714 FTE = 42/1 caseload)reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 10 to outpatient client treatment was 4 hours per week. The employee had 6 active clients as of May 16, 2018. - Employee # 10 (4/35 = .1142 FTE *** 6 clients/.1142 FTE = 53/1 caseload)These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program director will periodically review client caseloads and ensure they are following the standard of 35:1.
Both counselor's caseloads were incorrectly noted on the staffing sheet. The paperwork time was not included in the client activity. Also, it was noted based on the clients seen that week and not the clients scheduled. For instance, employee #8 was noted as 20 hrs per week, but having 24 clients. Not all of her clients attended that week, which is why it looks like she has more clients than hours spent with client activities. The same goes for employee #10.
Employee #8 had 24 clients. 28hrs per week was spent in client activity. (28/35=0.8000 24 clients/.8000 = FTE 30/1).
Employee # 10 had 6 clients. 7hrs per week spent in client activity. (7/35= .2000 6/.2= FTE 30/1). |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Six personnel records requiring documentation of instruction in the use of fire extinguishers were reviewed on May 23, 2018. The facility failed to document the completion of fire extinguisher training upon employment for employee record # 11. Employee # 11 was hired by the facility on 3/3/17 as a counselor. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program director will conduct fire safety training yearly with all staff. Program director will also check that every new hire has fire safety training documented on their orientation checklist within one month of being hired, |
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
Four client records were reviewed for the outpatient activity on May 23, 2018. The facility failed to document a treatment plan update at least every 60 days for client records # 1, 2, 3, and 4. Client # 1 was admitted into treatment on 1/30/18 and was still active in treatment. A comprehensive treatment plan was completed for the client on 2/26/18. The first treatment plan update documented in the client's record was completed on 5/9/17. Client # 2 was admitted into treatment on 11/28/17 and was discharged on 5/18/18. A comprehensive treatment plan was completed for the client on 12/18/17. The first treatment plan update documented in the client's record was completed on 3/5/18. Client # 3 was admitted into treatment on 7/13/17 and was discharged on 1/9/18. The first treatment plan update documented in the client's record was completed on 10/2/17. A subsequent treatment plan update was then completed on 1/2/18. Client # 4 was admitted into treatment on 6/27/17 and was discharged on 12/6/17. A comprehensive treatment plan was completed for the client on 7/18/17. The first treatment plan update documented in the client's record was completed on 10/3/17. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Treatment plans will be completed at least the week before they are due. If a client does not show to complete this, counselors will complete a treatment plan and sign it to review with the client at the next session.
Office Administrator will keep track of all treatment plans due and handed in and will alert the counselor and supervisors when one is due to be completed.
Program Director and Lead Counselor will review with counselors in supervision. |
709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
Four client records were reviewed for the intake, evaluation, and referral activity on May 23, 2018. The facility failed to document a consent to treatment for client records # 5, 6, 7, and 8. Client # 5 received an evaluation and referral for treatment services on 9/27/17. Client # 6 received an evaluation and referral for treatment services on 1/19/18. Client # 7 received an evaluation and referral for treatment services on 3/9/18. Client # 8 received an initial evaluation and referral for treatment services on 11/17/17, and then received a re-evaluation on 12/11/17. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Consent to treatment was added to assessment charts to be completed moving forward. Office administrator will ensure that they are being completed in all charts. Program Director and Lead Counselor will review with assessors in supervision. |
709.44(b)(4) LICENSURE Follow-up Information
709.44. Client records.
(b) If applicable, the project shall also include the following items in the client record:
(4) Follow-up information.
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Observations
Four client records were reviewed for the intake, evaluation, and referral activity on May 23, 2018. The facility failed to document follow-up information for client records # 6 and 7. Client # 6 received an evaluation and referral for treatment services on 1/19/18. Client # 7 received an evaluation and referral for treatment services on 3/9/18. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A follow up form was added to the assessment process. Assessors will call to follow up on clients within one month of going to treatment.
Program Director and Lead Counselor will review in supervision. |