INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19, 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, 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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704.11(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 TB/STD training within the first two years of employment.
A review of the Staffing Requirements Facility Summary Report was completed on February 19, 2020. Staff #12, a clerical staff, hired on May 17, 2017, did not have documentation of TB/STD training. This training was due to be completed by May 17, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Supervisor instructed the identified staff person to sign up for TB/STD training, which she has done. Clinical Director added list of DDAP required trainings to the criteria of the agency's internal mock audits when reviewing personnel files. Clinical Director also added reminder on new hire paperwork forms for Program Supervisors in DA to complete registry of DDAP required trainings for new hires as a mandatory part of their orientation. The outlined changes went into effect on 2/27/2020. |
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 #13, 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 46 contract hours per week. The employee had 70 active client as of February 19, 2020.
Employee # 13 (46/37.5 = 1.22 FTE *** 70 clients/1.22 FTE = 58/1 caseload)
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director advised Clinical Supervisor to add a "Caseload" discussion point to DA Staff Meeting form to check caseload ratios on a weekly basis with counselors. For counselors who did not attend the DA Staff Meeting, they will be required to review at a scheduled time with the Program Supervisor. Clinical Director explained new recruitment and hiring strategies with Program Supervisor who will be more proactive in ensuring the supply of counselors with respect to the volume of clients at the facility. These changes occurred on 2/27/2020. |