INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 5-8, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Arc Manor 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 May 4, 2010.
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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 a review of the staffing requirements facility summary report form completed by the facility on April 5, 2010 and an interview with the project director, the facility failed to ensure that counselor outpatient caseloads were at or below 35 active clients per one Full Time Equivalent (FTE) counselor.
The findings included:
On April 8, 2010, eight counselor outpatient caseloads were reviewed on the facility summary report form. Per regulation, the caseload for counseling in outpatient programs may not exceed 35 clients per one FTE counselor. Based on the number of hours the employees worked at the outpatient level of care, and the number of clients on the counselors' caseload, five counselors exceeded the maximum outpatient caseload of 35:1. The five caseloads that were over the maximum were: 106:1, 93:1, 53:1, 38:1 and 36:1.
The project director was interviewed on April 8, 2010. The project director confirmed these counselors were over the required caseload of 35:1. The facility director reported that two counselors recently left the program. The facility has hired three new counselors that will be starting on May 1, 2010.
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Plan of Correction
As mentioned in the findings report, ARC Manor was faced with the resignation of 2 full time counselors in a short period of time (Late February and Early March). Both positions were quickly filled in the month of March to ensure that ARC Manor would be able to provide continuous quality services to all of our clients. However, at the point of licensing, one new therapist (hired as a counselor assistant) was not able to carry a full caseload and one therapist (hired as a counselor) was in the training process. Both the Counselor Assistant and Counselor in question will be able to take on full outpatient caseloads in the next month. In addition, ARC Manor has continued to hire for full time therapists and we will have 2 new counselors and 1 counselor assistant beginning work at ARC Manor in the month of May. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 client record review and an interview with the project director, the facility failed to document follow up as per facility policy of one and six months in two of two client records.
The findings include:
Four inpatient client records were reviewed on April 6-7, 2010. Two of the four client records reviewed were that of discharged clients and therefore required follow up documentation at one and six months after discharge. The facility did not document a six month follow up in client records # 3 and 4.
Client #3 was admitted on June 23, 2009 and discharged on July 7, 2009. A one month follow up was documented on August 10, 2009. There was no documentation of a six month follow up which was due to be completed by January 7, 2010.
Client #4 was admitted on June 29, 2009 and discharged on August 17, 2009. A one month follow up was documented on September 15, 2009. There was no documentation of a six month follow up which was due to be completed by February 17, 2010.
An interview took place with the project director on April 8, 2010 at which time it was confirmed that there was no documentation of a six month follow up in client records #3 and #4.
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Plan of Correction
ARC Manor has a follow up procedure in place and follow up contact is attempted with all clients who are completely discharged from ARC Manor services. Follow ups occur at 1 month and 6 month intervals from the final discharge date. This process is managed by ARC Manor's Clinical Director. Follow up contacts are completed by ARC Manor support staff, and the paper follow up form is filed by Clinical Assistant support staff.
For the cases in question, the Clinical Director provided documentation that these clients were on the list to be contacted and it appears that the client's were contacted or that attempts were made to contact the individuals. However, there is a clear problem with the filing of the follow up forms by Clinical Assistant Support staff. ARC Manor's corrective action plan for this issue involves the current Electronic Health Record utilized by ARC Manor. As of 1/1/2010, all client files are entirely electronic and there will be no further need have support staff file the paper follow up form. The Clinical Director will generate the list of 1 and 6 month follow ups to be completed each month. This list will be provided to the support staff to make contact with discharged clients. After contact has been made or attempted, the follow up forms will be returned directly to the Clinical Director and all follow up information will be entered (data entry) into the client's electronic health record. This process will alleviate any issues of mis-filing a paper record. |