INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 19-20th 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Caron Counseling 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:
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Plan of Correction
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704.12(a)(5) LICENSURE Partial Hosp Ratio
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.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
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Observations
Based on a supervisory review of the written report of the onsite licensure inspection conducted on December 19 - 20, 2019, the facility failed to ensure that the facility did not exceed the maximum ratio of 10:1 for the Partial Hospitalization activity.
A supervisory review of the Staffing Requirements Facility Summary Report submitted by the facility, showed that the facility had a caseload of 13:1 for the Partial Hospitalization activity.
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Plan of Correction
A new counselor has been hired to carry a caseload that includes partial hospitalization patients and outpatient patients. This will bring the partial hospitalization patient/counselor ratio down to 9:1 which is in compliance with the state licensing required 10:1 ratio. The new counselor will have her own caseload as of 1/27/2020.
The Senior Director of Outpatient Services will monitor patient/counselor ratios on a daily basis to ensure ratios do not exceed the licensing requirements. Weekly, the patient/counselor ratios will be reported to the Compliance Department for monitoring adherence to the standards for the next 30 days. |
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
The Staffing Requirements Facility Summary Report was completed and reviewed on December 19-20th 2019.
Employee #3 was hired as lead counselor on May 27, 2003 and was still acting in that position. Employee #3 was reported to have 11 hours per week devoted to their 18 clients on her caseload.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by 40. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
The FTE counselor ' s caseload calculation is as follows: 11/40 = ..725(FTE); 18/..275 = 65.45, which equals to a client/counselor ratio of 66/1.
Employee #6 was hired a counselor on November 14, 2017 and was still acting in that position. Employee #6 was reported to have 5 hours per week devoted to their 9 clients on her caseload.
The FTE counselor ' s caseload calculation is as follows: 5/40 = .125(FTE); 9/.125= 72, which equals to a client/counselor ratio of 72/1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new counselor has been hired to carry a caseload that includes partial hospitalization patients and outpatient patients. This will bring the outpatient patient/counselor ratio down to 32:1 which is in compliance with the state licensing required 35:1 ratio. The new counselor will have her own caseload as of 1/27/2020.
The Senior Director of Outpatient Services will monitor patient/counselor ratios on a daily basis to ensure ratios do not exceed the licensing requirements. Weekly, the patient/counselor ratios will be reported to the Compliance Department for monitoring adherence to the standards for the next 30 days.
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