INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 17 -18, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility on 10-21-2014 and an interview with the QA and Compliance Director, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on 11-18-2014. The form listed six counselor's, and a facility director as clinical staff .The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based on the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard 40 hour work week and the total number of clients assigned to the following employees on 11-18-2014, employee # 1 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 35.
The number of hours per week devoted by Employee # 1 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 24 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee #1 had 29 active clients on November 18, 2014.
Employee #1 - 24/35 = .685 FTE 29 clients/.685 FTE = 43:1 caseload
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The increase in caseload for the identified staff is a result of two factors. One, the other local facility closed to new clients as of early October. This lead to an increase in the number of individuals seeking services. Secondly, our rapid access protocol provides a means for individuals to be admitted within a week of first contact. The resulting influx of clients lead to the increased caseload for our full time therapist. We feel an ethical responsibility to provide services, especially initial assessments to those who request them.
We are currently soliciting for a full-time drug and alcohol therapist and or contract therapist assistance. The plan is to have additional staff in place by January first at the latest. In the meantime we will also be redistributing some clients across other staff to decrease the variance from 35.
The Facility Director will be responsible for hiring the additional staff. Interviews are currently in progress and the target date for additional hires is January 1,2015.
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in three of ten client records.
The findings include:
Ten client records were reviewed on November 17 - 18, 2014. Ten of the ten client records were required to include an informed and voluntary consent from the client prior to the disclosure of information. Three of the ten records, #1, 8 and 9, did not obtain an informed consent prior to the disclosure of information.
Client #1 was admitted to treatment on 8-4-2014. A release of information for the Probation Department was signed by the client on 8-4-2014. The release did not include a witness signature.
Client #8 was admitted to treatment on 6-2-2014 and was discharged on 10-2-2014. A release of information was not signed for the funding source.
Client #9 was admitted to treatment on 4-21-2014 and was discharged on 8-6-2014. A release of information was not signed for the funding source.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Additional insurance funder consents and training for fiscal staff responsible for the completion of the consents will be completed by January 1, 2015.
Fiscal policy and procedure will be amended to address completion of consents in accordance with the regulations.
The absence of the witness signature is a result of computer error. Future issues of this nature will be addressed by printing a hard copy of the consent, signing and scanning the consent into the chart.
All of these actions will be complete by January 1, 2015. The Facility Director will be responsible for providing training and overseeing the additional changes. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a medical history in two of ten client records.
The findings include:
Ten client records were reviewed on November 17 - 18, 2014. All client records reviewed were required to document a medical history. The facility failed to provide documentation of a medical history in client records #3 and 10.
Client # 3 was admitted on 9-4-2014. The facility failed to document the completion of a medical history as of the date of the licensing inspection.
Client # 10 was admitted on 6-4-2014, and was discharged on 10-1-2014. The facility failed to document the completion of a medical history as of the date of the licensing inspection.
These findings were reveiwed with the facility staff during the licensing process.
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Plan of Correction
The lack of documentation of the medical histories in the chart appears to be a result of the protocol for handling the medical history form during the intake process.
All involved staff are currently reviewing this process. The team will develop an updated protocol to assure that all medical histories are attached to the client chart in a timely manner.
New policy and procedure will be developed and instituted to assure that this issue is corrected.
The facility director will be responsible for completing this correction. The target date for completion is January 1,2015. |