Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 1, an abbreviated off-site inspection, conducted on April 9, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.Based on the findings of Part 1, an abbreviated off-site inspection, Safe Harbor Behavioral Health of UPMC Hamot 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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Observations
The facility failed to maintain active outpatient caseloads at or below 35/1.The Staffing Requirements Facility Summary Report completed by facility staff documented the following:Counselor #5 works 3 hours per week in the Drug and Alcohol Activity. Counselor #5 is assigned 3 active Drug and Alcohol clients. The caseload calculation is: 3/40 (workweek) = .075 FTE. ---3/.075= 40 - 40/1 caseload.Counselor #6 works 40 hours per week in the Drug and Alcohol Activity. Counselor #6 is assigned 38 active Drug and Alcohol clients. The caseload calculation is: 40/40 (workweek) = .1 FTE. ---38/1= 38 --- 38/1 caseload.Counselor #7 works 40 hours per week in the Drug and Alcohol Activity. Counselor #7 is assigned 38 active Drug and Alcohol clients. The caseload calculation is: 40/40 (workweek) = .1 FTE. ---38/1= 38 --- 38/1 caseload.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor, Compliance Officer and Project Director will utilize the "how to calculate caseload ratios" worksheet to ensure caseload size requirements are met.
Clinical supervisor will monitor caseload sizes through direct supervisor with each clinician by completing overview of cases to ensure that each clinician's caseload size will not exceed 35/1, clinical supervisor will re-assign cases after 5/11/20 when a new clinician who has been hired is slated to start.
Clinical supervisor will re-assign cases and see clients as need to ensure that clinicians caseload sizes do not exceed 35/1.
This will be fully implemented by 5/30/2020. |