INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on June 2, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Freedom Healthcare Services, LLC 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
The drug and alcohol treatment project failed to provide documentation of a full-time clinical supervisor for every eight full-time counselors based on a review of the Staffing Requirements Facility Summary Reports for the two facilities within the project.
The Staffing Requirements Facilities Summary Reports for both facilities were dated May 22, 2020 and documented a total of 12.17 full-time counselors employed by the project. This number of full-time counselors would require a minimum of one full-time clinical supervisor.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.6 (a) Many of our staff were furloughed as a result of COVID 19 due to lack of childcare, caring for an elderly individual or the staff's physician recommending they quarantine due to health issues. As a result of this our clinical supervisors increased their caseloads to put treatment first and assure that all patients received counseling services. F.H.S is working to resolve this issue by bringing staff back to work, this process began on May 28, 2020. As staff return to work, patients will return to their primary counselor thus reducing the caseloads of the Supervisors. These changes will be made by the end of June, this will be the responsibility of the Clinical Director. F.H.S will have a full-time clinical supervisor for every eight full-time counselors. The clinical director will monitor the number of FTE counselors to ensure there is one full time supervisor for every 8 FTE counselors. To ensure that this does not reoccur the Clinical Director will review the number of FTE to the number of clinical supervisors on a monthly basis and upon the hiring/dismissal of any counselors.
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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
The facility failed to ensure that each counselor's caseload remained at or below 35 active clients based on a review of the facility's Staffing Requirements Facility Summary Report.
Based on the total number of hours per week devoted to each client and the facility's standard work week of 35 hours as documented on the Staffing Requirements Facility Summary Report dated May 22, 2020, employees # 5, 6, 7 exceeded the allowable maximum 35/1 caseload.
Employee # 5 worked 35 hours per week and had 41 active clients.
(35 hours/35 hours = 1 FTE - 41 clients/1 FTE = 41/1 caseload)
Employee # 6 worked 18 hours per week and had 20 active clients.
(18 hours/35 hours = .514 FTE - 20 clients/.514 FTE = 39/1 caseload)
Employee # 7 worked 25 hours per week and had 27 active clients.
(25 hours/35 hours = .714 FTE - 27 clients/.714 FTE = 38/1 caseload)
The findings were reviewed by facility staff during the licensing process.
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Plan of Correction
704.12 (a)(6) Counselor caseloads were over the 35 active clients due to many of our staff being furloughed as a result of COVID 19. Staff were furloughed because of lack of childcare, caring for an elderly individual or the staff's physician recommending they quarantine due to health issues. F.H.S is working to resolve this issue by bringing staff back to work, this process began on May 28, 2020. All staff will be returned to work and each counselors caseload will not exceed 35 active clients by the end of June, the Clinical Director will be responsible for reducing caseloads back to 35 active patients. Currently (June 12) employees # 6,7 have caseloads that do not exceed 35/1. Employee # 5 will not have caseloads that exceed 35/1 by end of June, this will be the responsibly of the clinical director. The clinical director will monitor the number of patients on each counselor's caseload on a weekly basis to ensure that caseloads do not exceed 35 active patients in the future. |