INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 24, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, SPHS Behavioral Health 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 a review of the staffing Requirements Facility Summary Report, the facility failed to maintain the outpatient counselor caseloads at or below 35/1 in four out the sixteen counselor caseloads.
Counselor #6 works 42 hours at the facility with 42 of those hours being dedicated to D/A clients. The facility's work week is 37.5 hours, therefore, 42/37.5=1.12 FTE. Counselor #6's D/A caseload is currently 41 active D/A clients. Therefore, 41/1.12=36.60 or 36/1 which exceeds the maximum of 35/1.
Counselor #12 works 37.5 hours at the facility with 37.5 of those hours being dedicated to D/A clients. The facility ' s work week is 37.5 hours, therefore 37.5/37.5=1 FTE. Counselor #12's D/A caseload is currently 38 active D/A clients. Therefore 38/1=38 which exceeds the maximum of 35/1.
Counselor #18 works 20 hours at the facility with 10 of those hours being dedicated to D/A clients. The facility's work week is 37.5 hours. therefore 10/37.5=.266 FTE. Counselor #18's D/A caseload is currently 10 active D/A clients. Therefore 10/.266=37.59 or 37/1 which exceeds the maximum of 35/1.
Counselor #20 works 8 hours at the facility with 8 of those hours being dedicated to D/A clients. The facility's work week is 37.5 hours, therefore 8/37.5=.213 FTE. Counselor #20 D/A caseload is currently 8 active D/A clients. Therefore. 8/.213=37.55 of 37/1 which exceeds the maximum 35/1.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from inspections completed on February 19, 2020 and February 8, 2021, ending on February 19, 2021.
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Plan of Correction
Clinical Supervisors will meet with Clinicians weekly, as documented through supervision logs, to discuss cases and caseloads to ensure that all client needs are being met and the clinicians are staying within the 1/35 clinician to client ratio. Clinical supervisors will continue to explore options for the recruitment of additional staff. Clinical Director will maintain contact with Clinical supervisors to monitor caseloads. If at any time caseloads fail to meet regulatory standards, Clinical Director will meet with agency Executives to explore options, which include but are not limited to closing for referrals. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the client records, the facility failed to document written acknowledgement by the clients that they have been notified of those rights specifically that the project may not discriminate on the basis of age in seven out of seven client records reviewed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Client Orientation Packet provided to every client at the time of their initial evaluation was amended by the Clinical Director on 1/26/2022 to include the approved nondiscriminatory policy wording, "Our Program will not deny service to any client based on age, ethnicity, race, color, sexual orientation, or national origin, marital status, sex, handicap, or religion/creed. The Program will follow all Federal, State, and Local laws concerning Program services." All new clients will electronically sign an Orientation Packet Checklist in Credible indicating that they received a copy of said packet and Non-Discrimination policy. All previous copies of the orientation packet have been removed from the facility. A digital copy was also sent to all staff to offer to current clients who may have received the previous version. |