INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 21 through 22, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Path Incorporated was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
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.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility on May 21, 2012, the facility failed to ensure that the staff to client ratios remained at or below 35:1. The findings include: On May 21, 2012 the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed the project director/facility director, two clinical supervisors and seven counselors for the 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 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 work week (40), and the total number of current clients as of May 21, 2012 exceeded the allowable maximum of 35:1. The actual client ratio 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 work week. The number of hours per week for employee #6 was 24 hours devoted to drug and alcohol clients. 24 divided by the facility work week of 40 hours equals 0.6 FTE. The number of current clients is 22 divided by the 0.6 FTE is 36.6666666666. This results in a ratio of 37:1 which exceeded the maximum of 35:1.The number of hours per week for employee #8 was 37.5 hours devoted to drug and alcohol clients. 37.5 divided by the facility work week of 40 hours equals 0.9375 FTE. The number of current clients is 35 divided by the 0.9375 FTE is 37.333333333. This results in a ratio of 38:1 which exceeded the maximum of 35:1.The number of hours per week for employee #10 was 37.5 hours devoted to drug and alcohol clients. 37.5 divided by the facility work week of 40 hours equals 0.9375 FTE. The number of current clients is 33 divided by the 0.9375 FTE is 35.2. This results in a ratio of 36:1 which exceeded the maximum of 35:1.
|
Plan of Correction
PATH's Employee Handbook clearly defines a full-time employee as someone who is regularly schedules to work a minimum of 37.5 hours per week. We also have some full-time employees who work 40 hours per week. However, the employees who work 37.5 hours are full-time employees and receive full benefits. Because some some therapists work 40 hours per week, the 37.5 hr employees were classified as 0.9375 FTE at the time of the licensing visit
and their maximum caseload size was reduced accordingly. We disagree with this interpretation and will request further
clarification. However, we understand that we must have a plan to be in compliance with this interpretation. Therefore,staff will not be permitted to work more than 37.5 hours in the D&A program and the maximum caseload size will remain 35:1.
The outpatient director assigns all new cases to D&A therapists. When assigning new cases, the outpatient director will review the therapists present caseload to ensure that the new case assignment will not exceed the 35:1 ratio. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in nine of ten client records. The findings include:Ten client records were reviewed on May 22, 2012. A psychosocial evaluation was required in eight client records, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. An interview with facility staff on May 22, 2012 confirmed the findings. The psychosocial evaluations in client records #1, 2, 3, 5 and 8 did not include an evaluation of the client's assets/strengths and how they would impact treatment. The psychosocial evaluations in client records #1, 2, 3, 4, 5 and 8 did not include an evaluation of the client's support systems and how they would relate to treatment. The psychosocial evaluations in client records #1, 2, 3, 5 and 8 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment. The psychosocial evaluations in client records #1, 2, 3, 5 and 8 did not include an evaluation of the client's negative factors and how they would impact treatment. The psychosocial evaluations in client records # 3 and 8 did not include an evaluation of the client's attitude toward treatment and how they would impact treatment. The psychosocial evaluations in client records #1, 2, 3, 4, 5 and 8 did not include an evaluation of the counselor conclusions/impressions of the client.Additionally, per the facility's policy, psychosocial evaluations are the be completed within 45 days after admission. Client #5 was admitted on January 27, 2012 and their psychosocial evaluation was to be completed by March 13, 2012. Client #5's psychosocial evaluation was completed on April 10, 2012, 28 days past the required timeframe for completion.Client # 6 was admitted on December 8, 2011 and discharged on March 6, 2012. The psychosocial evaluation was to be completed by January 23, 2012. As of the date of the discharge, client #6's psychosocial evaluation was not documented.Client # 7 was admitted on November 10, 2011 and discharged on March 8, 2012. The psychosocial evaluation was to be completed by December 25, 2012. As of the date of the discharge, client #7's psychosocial evaluation was not documented.Client # 10 was admitted on August 26, 2011 and discharged on January 12, 2012. The psychosocial evaluation was to be completed by October 5, 2012. As of the date of the discharge, client #10's psychosocial evaluation was not documented.
|
Plan of Correction
The facility director will ensure that all D&A program staff receive comprehensive training on the psychosocial evaluation. Training will include:
1)an evauation of the client's assets/stenghts and how they may impact treatment;
2)an evaluation of the client's support systems and how they relate to treatment:
3)an evaluation of the client's coping mechanisms and how they may relate to or impact treatment;
4)an evaluation of the client's negative factor's and how they may impact treatnment;
5)an evaluation of the client's attitude and how it may impact upon treatment;and
6)an evaluation of the counselor conclusions/impresasions of the client.
In addition to the above data, the training will also focus on PATH's policy requirement that all psychoscial evaluations be completed within 45 days of admission. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of client records, the facility failed to document treatment plans within the facility's required time frame in six of ten client records.The finding includes:Ten client records were reviewed on May 22, 2012. Treatment plans were reviewed in nine client records, #1, 2, 3, 4, 5, 6, 7, 9 and 10. Per the facility's policy, treatment plans will be completed within 45 days of the client's admission date and after the completion of the client's biopsychosocial history and evaluation. Client #4 was admitted on October 5, 2011 and their treatment plan was completed on October 5, 2011. Client record #4's treatment plan was completed on October 5, 2011, prior to the completion of the client's psychosocial evaluation which was completed on November 16, 2011. Client #5 was admitted on January 27, 2012 and their treatment plan was completed on March 12, 2012. Client record #5's treatment plan was completed on March 12, 2012, prior to the completion of the client's psychosocial evaluation which was completed on April 10, 2012. Client #6 was admitted on December 8, 2011 and discharged on March 6, 2012. The treatment plan was completed on January 4, 2012. Client record #6's treatment plan was completed on January 4, 2012 prior to the completion of the client's psychosocial evaluation which was not documented for review. Client #7 was admitted on November 10, 2011 and discharged on March 8, 2012. The treatment plan was completed on March 8, 2012. Client record #7's treatment plan was completed on January 9, 2012, prior to the completion of the client's psychosocial evaluation which was not documented for review. Client #9 was admitted on March 5, 2012 and discharged on April 11, 2012. The treatment plan was completed on April 5, 2012. Client record #9's treatment plan was completed on April 5, 2012, prior to the completion of the client's psychosocial evaluation which was not documented for review. Client #10 was admitted on August 26, 2011 and discharged on January 12, 2012. The treatment plan was to be completed by October 10, 2011. As of the date of client #10's discharge January 12, 2012, there was not documentation of the clients treatment plan.A discussion with facility staff on May 22, 2012 confirmed the findings.
|
Plan of Correction
The facility director will ensure that all staff receive training regarding the requirement that treatment plans be completed within 45 days of the client's admission to the D&A program.
The outpatient director conducts quarterly ecord audits in coordination with PATH's Quality Improvement department. The audit process will be revised to ensure that the treatment plan is completed within 45 days of admission to the program and after completion of the client's biopsychosocial history and evaluation. Any non-compliance in this area will be addressed with the therapist. |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document case consultations notes in four of seven client records.Findings:Ten client records were reviewed on May 22. Per the facility's policy, case consultations are to be documented every 90 days after admission. An interview with the facility staff on May 22, 2012 confirmed the findings.Client #2 was admitted on November 29, 2011 and the case consultation was due by February 29, 2012. Client #2's case consultation was documented on March 28, 2012. Client #3 was admitted on October 28, 2011 and the case consultation was due by January 28, 2012. Client #2's case consultation was documented on February 10, 2012. Client #7 was admitted on November 10, 2011 and discharged on March 8, 2012. As of the date of the client's discharge March 8, 2012, client #7 did not have documentation of a case consultation. Client #10 was admitted on August 26, 2011 and discharged on January 12, 2012. As of the date of the client's discharge January 12, 2012, client #10 did not have documentation of a case consultation.
|
Plan of Correction
The facilty director will ensure that all staff recive training re:the requirement to document case consultaion notes in client records. PATH will also update our policy to define the timeline for the notes as every 3 months after admission as opposed to every 90 days. This meets the quartely requirement.
The outpatient director routinely completes quarterly record audits in coordination with PATH's Qualty Improvement Department. The completion of case consultations every 3 months will be added to the audit form and reviewed by the program director. Any non-compliance with this standard will be addressed with the staff member. |
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.
|
Observations
Based on a review of client records, the facility failed to document follow-up attempts in three of five required records. The findings include: Ten client records were reviewed on May 22, 2012. Five of those ten records were required to document follow-up attempts. Per the facility policy, follow-up will take place 7 days for referrals and 60 days all other discharges. Follow up was not documented in record, #7, 8 and 10. An interview with facility staff on May 22, 2012 confirmed the findings.Client record # 7 was admitted on November 10, 2011 and discharged on March 8, 2012. The follow up attempt was due on May 8, 2012. As of the date of the licensing inspection there was no documentation of a follow-up attempt in client record #7.Client record # 8 was admitted on December 5, 2011 and discharged on February 23, 2012. The follow up attempt was due on April 24, 2012. As of the date of the licensing inspection there was no documentation of a follow-up attempt in client record #8.Client record # 10 was admitted on August 26, 2011 and discharged on January 12, 2012. The follow up attempt was due on March 13, 2012. As of the date of the licensing inspection there was no documentation of a follow-up attempt in client record #10..
|
Plan of Correction
The facility director will ensure that all D&A staff recive training re: the need to provide and document follow-up within 7 days for referrals and 60 days for all other discharges.
The outpatient director reviews all discharges and will schedule a review 5 days prior to the follow-up due date (2 days for referrals and 55 days for all other discharges)to determine if the follow up has occurred. If follow-up has not occurred, the program director will ensure that it occurs prior to the deadline. |