INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 24-25, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, The Care Center dba SPHS Care Center 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to document HIV/AIDS and TB/STD training within the first year of employment for counselors.
A review of the Staffing Requirements Facility Summary Report was completed on February 24, 2020.
Staff #13, a counselor, hired on May 17, 2018, did not have documentation of TB/STD and HIV/AIDS training. This training was due to be completed by May 17, 2019.
Staff #14, a counselor, hired on June 19, 2018, did not have documentation of TB/STD and HIV/AIDS training. This training was due to be completed by June 19, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 04/01/2020 a mandatory staff meeting will be held with all staff to review mandatory training guidelines. Staff members who need to be scheduled for their Mandatory Communicable Disease Training will be scheduled and completed by 07/01/2020. All new clinical staff will be scheduled for their Mandatory Communicable Disease training within the first year that they are employed. The Clinical Supervisor will be responsible for this plan of correction and ongoing monitoring of same. |
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 facility failed to ensure that outpatient staff caseloads remain at or under 35:1.
Based on the total number of hours per week devoted to clients, and the facility's standard work week of 37.5 hours, employee #5, exceeded the allowable maximum 35:1 caseload.
As reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 13 to outpatient client treatment was 31.5 contract hours per week. The employee had 30 active clienst as of February 24-25, 2020.
Employee # 5 (31.5/37.5 = .84 FTE *** 30 clients/.84 FTE = 35.71 - 36/1 caseload)
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identified caseload has since been brought into compliance. It is the responsibility of the clinical supervisor to review caseloads weekly in staffing to ensure capacity compliance. Clinical supervisor will assign cases in accordance to the client/staff ratios. This process will be reviewed with all staff by 04/01/2020 to ensure supervisor is assigning cases accordingly. Clinical Supervisor will be responsible for this plan of correction and ongoing monitoring of same. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to review and update treatment plans at least every 60 days.
Client records were reviewed on February 24-25, 2020. Client records #2, 3, 4, 6, 7 and 9 contained treatment plans that were not documented to be reviewed at least every 60 days.
Client #2 was admitted on January 30, 2019 and is currently active. The last treatment plan review was documented on November 4, 2019. A treatment plan review/update was due to be completed by January 4, 2020.
Client #3 was admitted on February 6, 2019 and is currently active. A treatment plan review/update was completed September 10, 2019. The next treatment plan review/update was due to be completed November 10, 2019. It was documented on January 10, 2020.
Client #4 was admitted on October 9, 2019 and is currently active. The last treatment plan review/update was completed December 5, 2019. The next treatment plan review/update was due to be completed February 5, 2020.
Client #6 was admitted on April 2, 2019 and discharged on December 17, 2019. The last treatment plan review/update was completed September 3, 2019. The next treatment plan review/update was due to be completed November 3, 2019.
Client #7 was admitted on March 21, 2019 and discharged on August 8, 2019. The initial treatment plan was completed on March 21, 2019 and was due to be reviewed/updated on May 21, 2019 and again on July 21, 2019. There was only one treatment plan update documented on June 6, 2019.
Client #9 was admitted on July 15, 2019 and discharged on January 5, 2020. The latest treatment plan was completed on September 26, 2019 and was due to be reviewed/updated on November 26, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The referenced client records will be corrected. The Clinical Supervisor will review the requirement to complete the treatment plan update and regulatory standards with an emphasis on due dates and timelines. A training will be held for staff as part of the staff meetings and clinical support to provide direct instruction on effectively documenting treatment plan update within the specific due dates. Each staff member will be provided with a copy of our agency's policy and regulations in regard to treatment plan timelines. This will be conducted by the Clinical Supervisor and completed by 04/01/2020. Clinical Supervisor will continue to review and treatment plan updates through internal chart reviews and supervision on an ongoing basis. Clinical Supervisor will be responsible for this plan of correction and ongoing monitoring of same. |