INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on November 3 - 4, 2015, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Counseling of Mercer County was not found 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on the review of staff records and an interview with the facility director, the facility did not have a mechanism in place to collect feedback for completed training.
The findings include:
Three out of the three staff records reviewed that required feedback for completed training, did not have documentation of feedback for the completed training.
Employee #2 was hired on 11/02/2009, as a counselor. During the onsite inspection conducted on 11/04/2015, the facility had no documentation of feedback from Employee #2 for the training completed in the 07/01/2014, through 06/30/2015, training year.
Employee #3 was hired on 06/23/2008, as a counselor. During the onsite inspection conducted on 11/04/2015, the facility had no documentation of feedback from Employee #3 for the training completed in the 07/01/2014, through 06/30/2015, training year.
Employee #4 was hired on 12/13/2011, as a counselor. During the onsite inspection conducted on 11/04/2015, the facility had no documentation of feedback from Employee #4 for the training completed in the 07/01/2014, through 06/30/2015, training year.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A brief feedback form has been developed and added to the electronic system. It was initiated when several outpatient therapists attended training last week.The form is completed and submitted to HR for addition to the personnel chart.
It is the responsibility of the clinician to complete the feedback form for each training attended. The Facility Director and the HR Director will be responsible for monitoring compliance with the requirement following each training. The official initiation date was 11/20/2015.
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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 Form, and an interview with the facility director, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
The Staffing Requirements Facility Summary Report Form was reviewed on 11/03/2015 and 11/04/2015. The form listed four counselors and one counselor assistant. After interviewing the facility director, it was determined that the job duties of the counselor assistant did not meet the criteria for a counselor or counselor assistant. The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report Form, was 40 hours per week.
Based on the total number of hours per week that the facility reported the counselors devoted to their clients, the total number of hours in the facility's standard 40 hour work week and the total number of clients assigned to the following counselors on 11/03/2015 and 11/04/2015, Counselor #2 exceeded the maximum allowed caseload of 35:1.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by 35.
The number of hours per week devoted by Counselor #2 to treatment, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 27. The facility reported on the Staffing Requirements Facility Summary Report form that Counselor #2 had 29 active drug and alcohol clients on November 3, 2015, and November 4, 2015.
Counselor #2 - 27/35 = .771 FTE 29 clients/.771 FTE = 38:1 caseload
The findings were reviewed with the facility staff during the licensing process.
This is a repeat citation. the facility was previously cited for non-compliance with this standard during the 11/17/2014, and 11/18/2014, inspection.
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Plan of Correction
The current lack of availability of services in Mercer County since October of 2014 has lead to an over utilization of the services at CCC. We have and will continue to attempt to maintain the 35:1 ratio to the best of our ability. As shared in the licensing interview, we had recently closed referrals from all referral sources in order to remain within capacity.
Additionally, requests for a waiver were sent to the Department of Drug and Alcohol, along with correspondence from our SCA requesting exception due to lack of additional facilities. No response has been received concerning this issue. It is very difficult to monitor caseloads with the influx of clients requesting services.
Currently, caseloads will be monitored weekly for compliance and every effort will be made to keep caseloads under 35 :1. It is the responsibility of the facility director to review these numbers and shift cases or close referrals as necessary.
Additionally, we are going to be following up with the Department to attempt to get a waiver until a new facility is opened in the county. This is an ongoing process already occurring. |