INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 25, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Treatment 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)(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 review of The Staffing Requirements Facility Summary Report, the FTE counselor caseload for two counselors in the outpatient program exceeded 35 active clients.Employee # 3 was hired as a Clinical Supervisor on October 16, 2002 and was still in this position at the time of the inspection. Employee #3 was reported to have 30 hours per week devoted to their 34 clients on their caseload.The FTE counselor ' s caseload calculation is as follows: 30/37.5 = .8(FTE); 34/.8 = 42.5, which equals to a client/counselor ratio of 42:1.Employee # 5 was hired as a Clinical Supervisor on April 15, 1988 and was still in this position at the time of the inspection. Employee #5 was reported to have 30 hours per week devoted to their 34 clients on their caseload.The FTE counselor ' s caseload calculation is as follows: 30/37.5 = .8(FTE); 34/.8 = 42.5, which equals to a client/counselor ratio of 42:1.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We will continue to monitor caseload sizes on a weekly basis in our QA meeting on Mondays. After talking with the license facilitator, we were able to understand the full time equivalency standards better and have already calculated new caseload sizes for staff with split duties. The caseloads have been appropriately adjusted and staff members were made aware of their case load numbers. This will be monitored weekly ongoing.
This process will be monitored weekly in our QA meeting by the Clinical Director, who will focus on caseload numbers weekly to ensure com pliancy.
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client record # 1. Client # 1 was admitted on July 18, 2022 and was still active at the time of the inspection. A letter was sent to an outside agency on July 18, 2022 however, an informed and voluntary consent from the client for the disclosure of information was not signed by the client until July 30, 2022. Also, funding authorizations for the client occurred upon admission however, an informed and voluntary consent from the client for the disclosure of information was not signed by the client until July 30, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-trained about the necessity of releases being signed by patients before any correspondence is to happen. Since telehealth sessions are still happening at our Agency, we have stressed the importance of patients coming to the Agency for face to face sessions for at least the intake sessions in order to obtain their signatures for this mistake not to happen. Front staff and intake were made aware that intakes need to happen in-person so these signatures are obtained immediately entering treatment.
Executive Director and Clinical Director will have a staff training on March 2, 2023 to discuss the importance of this in detail.
Clinical Director will randomly conduct case file reviews on intake staff to make sure releases are being signed at the admission level.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on seven of seven client records reviewed, the facility failed to provide a preliminary treatment plan in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated a preliminary treatment plan be completed during intake.Client # 1 was admitted on July 18, 2022 and was still active at the time of the inspection. There was no preliminary treatment available in the client record. Client # 2 was admitted on October 4, 2022 and was still active at the time of the inspection. There was no preliminary treatment available in the client record. Client # 3 was admitted on October 17, 2022 and was still active at the time of the inspection. There was no preliminary treatment available in the client record. Client # 4 was admitted on August 29, 2022 and was still active at the time of the inspection. There was no preliminary treatment available in the client record. Client # 5 was admitted on May 13, 2022 and was discharged on September 13, 2022. There was no preliminary treatment available in the client record. Client # 6 was admitted on April 5, 2022 and was discharged on October 7, 2022. There was no preliminary treatment available in the client record. Client # 7 was admitted on August 5, 2022 and was discharged on October 24, 2022. There was no preliminary treatment available in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We will implement changes in policy to identify the initial treatment plan to be completed by intake staff on the second intake appointment and the primary counselor to complete the comprehensive treatment plan on the first session they meet the patient. The counselor and patient will collectively work together on creating treatment plan goals to works towards achieving while in treatment.
Executive Director and Clinical Director will make sure these changes are in effect immediately in the policy. All staff will be asked to review the new policy to understand our treatment plan process and the importance it has for ongoing treatment benefits for our patients.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on one of two applicable client records reviewed, the facility failed to provide an aftercare plan upon successful discharge of client # 7.Client # 7 was admitted on August 5, 2022 and was discharged on October 24, 2022. There was no aftercare plan available in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An aftercare plan should be completed for all successful discharge charts. This was an intake chart that did not need further treatment so was discharged due to no treatment needed, not necessarily a successful discharge since there was no treatment plan goals addressed and completed.
Policy and procedure manual will be changed to understand this more concretely.
Executive Director and Clinical Director will re-educate the staff regarding after care plans and the importance of this form to be completed. A staff training will be completed on March 2 ,2023.
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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.
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Observations
Based on one of two applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur 30-60 days after discharge by phone.Client # 7 was admitted on August 5, 2022 and was discharged on October 24, 2022. There was no follow-up information available in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The follow up process and protocol will also be addressed and updated in our policy and procedure manual. Staff will be re-trained as to discuss best practice and the Agency protocols to follow for follow- up procedures in the Agency.
Executive Director and Clinical Director will re-educate the staff regarding the follow up process for patient cases. Any changes made in policy will require staff to review and understand.
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