INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 7 - 8, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Bucks County Council on Alcoholism and Drug Dependence Services, Doylestown 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 and a plan of correction is due on March 16, 2011.
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
During a supervisory review of your licensing packet, the reviewer determined that the Staffing Requirements Facility Summary Report form completed by the facility on February 7, 2011 was incomplete.
Findings:
The Staffing Requirements Facility Summary Report that was presented to the Licensing Specialist was incomplete.
Page two of the Staffing Requirements Facility Summary Report in reference to employee #1 was incomplete. The information provided for employee # 1 did not include the number of training hours obtained by the employee for HIV/AIDS training or for TB/STD and other communicable diseases training. In addition, the reference to the annual training requirements for employee # 1 was incomplete and failed to list the subject area and provider for the training obtained.
Page three of the Staffing Requirements Facility Summary Report did not include the educational institution which granted the degrees for employees # 2, 3, 4 and 5, and it failed to include the date the degrees were granted for employees # 4 & 5.
Page four of the Staffing Requirements Facility Summary Report did not include the provider of the HIV/AIDS and TB/STD training for employee # 2, 3, 4, and 5.
Page seven of the Staffing Requirements Facility Summary Report failed to include the medical director, the date of hire, and whether he/she completed HIV/AIDS training.
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Plan of Correction
The Staffing Requirements Facility Summary Report will now include the number of training hours for HIV/AIDS and/or TB/STD and other communicable diseases and will also list the provider of the training. The additional training hours will be attached containing the subject area and provider information. Changes will be made by the director of operations by 3/31/2011 and will be confirmed by the clinical supervisor on that date. This will continue in the future with the clinical supervisor confirming all information is included in the above-mentioned-form prior to submission to licensing.
All Degreed employees will now reflect the date and facility from which the degree was issued. Changes will be made by the director of operations by 3/31/2011 and will be confirmed by the clinical supervisor on that date. This will continue in the future with the clinical supervisor confirming all information is included in the above-mentioned-form prior to submission to licensing.
The director of operations will look to contract/hire a medical director. |
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 February 7, 2011 and a discussion with the facility director and clinical supervisor on February 8, 2011, the facility failed to ensure that staff to client caseloads remained at or under 35:1.
The findings included:
On February 8, 2011 the Staffing Requirements Facility Summary Report form completed by the facility was reviewed.
The form listed three counselors, a clinical supervisor, and the project/facility director for the clinical staff; however, the facility only documented two counselors, employees # 3 & 5, as having clients on a caseload.
The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report, was 35 hours per week.
Based on the 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, 35, and the total number of clients assigned to the following employees on February 7, 2011 and February 8, 2011, employees # 3 and 5 were assigned caseloads that exceeded the maximum caseload of 35:1.
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 clinical treatment by the facility's standard workweek.
The number or hours per week devoted by employee # 3 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 7 hours per week.
The facility reported on the Staffing Requirements Facility Summary Report form that employee # 3 had 11 active clients on February 7, 2011 and February 8, 2011.
Employee # 3 (7/35 = 0.2 FTE11 clients/0.2 FTE = 55:1 caseload)
The number or hours per week devoted by employee # 5 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 7 hours per week.
The facility reported on the Staffing Requirements Facility Summary Report form that employee # 5 had 10 active clients on February 7, 2011 and February 8, 2011.
Employee # 5 (7/35 = 0.2 FTE10 clients/0.2 FTE = 50:1 caseload)
This is a repeat deficiency. Findings from the February 18, 2010 inspection regarding caseload size revealed caseloads of 63:1 and 46:1. Findings from the March 25, 2009 inspection regarding caseload size revealed a caseload of 60:1.
The facility director and clinical supervisor confirmed that the caseloads exceeded 35:1.
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Plan of Correction
Upon further discussion of the citation with one of the supervisors at DAPL, we believe the facility had not documented the correct number of hours dedicated to the D/A client. We were not documenting all the time spent with the client that was not face to face.
We are reviewing the actual time spent on clients and will resubmit documentation showing that we are at or below the 35:1 caseload regulation. This will be reviewed and resubmitted by the clinical supervisor by 4/15/2011.
We are going to insure the number of hours dedicated to clients is documented on the Staffing Requirements Facility Summary Report. We are going to maintain supporting documentation of this form. Supporting documentation will be in the form of a time sheet that will be signed off on by the therapist verifying time spent with clients. The clinical supervisor will review this time sheet on a monthly basis.
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