INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 22 - 24, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cen-Clear Child Services, Inc. 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the Staffing Requirements Facility Summary Report form completed by the facility on August 22, 2011 and an interview with the facility director, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of four personnel records.
The findings include:
Seven personnel records were reviewed on August 22, 2011. Five personnel records pertained to counselors. Four personnel records required documentation of 25 clock hours of annual training. One counselor was a new hire and not yet required to complete 25 clock hours of training. The facility failed to document 25 clock hours of required annual training in personnel record # 6.
Employee # 6 was hired for the position of counselor on March 26, 2009. The facility training year is from August through July. Employee # 6 only completed 19 clock hours of annual training from August 1, 2010 through July 31, 2011. No other documentation of training hours was available for review during the licensing inspection conducted on August 22 - 24, 2011.
The facility director was interviewed on August 23, 2011 at approximately 9:00 AM and confirmed the findings. Employee # 6 was on leave and not available to interview.
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Plan of Correction
The facility director will be responsible for monitoring that all 25 hours of training is completed for all clinical staff (full and part time). Employee #6 was informed that he is required to complete 25 hrs per year of training in a the field. |
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 August 22, 2011 and an interview with the project director, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
On August 22, 2011, the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The facility listed the project director, facility director/clinical supervisor, four counselors and one counselor assistant. The facility director/clinical supervisor, four counselors and one counselor assistant have caseloads documented on the staffing form.
The standard work week of the facility is 37.5 hours per week.
Based on the total number of hours that the facility reported the employees dedicated to their clients, the total number of hours in the standard work week of the facility and the total number of clients assigned to the following employees on August 22, 2011; employees # 3 and 7 exceeded the allowable maximum 35:1 caseload.
The number of hours per week dedicated by employee # 3 to client treatment, as reported on the Staffing Requirements Facility Summary Report, was 37.5 hours per week. The facility reported on the staffing form that employee # 3 had 52 active clients on August 22, 2011.
Employee # 3:
37.5 hours/37.5 hours = 1 FTE (full time equivalent), 52 clients/1 FTE = 52:1 caseload
Employee # 7
37.5 hours/37.5 hours = 1 FTE (full time equivalent), 55 clients/1 FTE = 55:1 caseload
The project director was interviewed throughout the licensing process and confirmed that employees # 3 and 7 had a caseload exceeding the allowable maximum caseload of 35:1.
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Plan of Correction
The program director is advertising to hire additional part time staff to meet the staff FTE ratio requirement. No therapist will have a caseload above the 35 clients. The facility director will review therapist caseloads on a weekly basis to determine staff ratio and compliance of 35:1 ratio is consistent. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection completed on August 24, 2011 from approximately 9:15 AM to 9:45 AM and staff interviews, the facility failed to ensure fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
The findings include:
A physical plant inspection was conducted on August 24, 2011 from approximately 9:15 AM to 9:45 AM. The facility has four fire extinguishers. The fire extinguishers are required to be inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguishers each have a tag from the manufacturer. These tags have the word "new" written on them with the date 11/5/2010, and initials next to the date. There was no documentation that the fire extinguishers were inspected by the local fire department or fire extinguisher company, at the time of the review on August 24, 2011.
On August 24, 2011, the Departmental Assistant was interviewed at approximately 9:30 AM. The Departmental Assistant reviewed the tags on the fire extinguishers and reported that the fire extinguishers were inspected by a staff member of the project's safety committee. The project director was also interviewed on August 24, 2011 and confirmed that these fire extinguishers had never been inspected by a local fire department or fire extinguisher company, as required. The project director reported this issue will be corrected as soon as possible.
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Plan of Correction
The fire extingquishers were inspected by an independent fire extinguisher company august 26, 2011. Annual fire extinguishers inspections will be the responsibility of the Assistant to the Executive to ensure that they are completed annually. She has developed a schedule that all facilities will be inspected in the month June on an annual basis. The Assistant to the Executive will assure and is responsible for making sure that all facilities are within regulation. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of policies and procedures, client records and staff interviews, the facility failed to document medical, drug/alcohol and personal histories according to the facility's written procedures for the management of treatment/rehabilitation services for clients in five of eight client records. In addition, the facility failed to document a written procedure that requires the development of a psychosocial evaluation based on the collected historical information of the client.
The findings include:
The facility's policy and procedure manual was reviewed on August 22, 2011. Sixteen client records were reviewed on August 23 - 24, 2011. Eight client records were reviewed for client histories and psychosocial evaluations. The facility utilizes a file check-in list, documented as D & A form 22. Per the facility's written procedure and D & A form 22, the counselor is required to complete the psychosocial evaluation by the client's second counseling session. The counselor then is required to complete the intake paperwork, which includes the medical, drug/alcohol and personal histories, by the fifth counseling session. Per regulation, the psychosocial evaluation should provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation. The facility procedure requires the counselor to complete the psychosocial evaluation prior to actually collecting the historical information. This is inconsistent with the regulation; which requires the psychosocial evaluation to be based on the collected historical information. The facility failed to document a written procedure that requires the development of a psychosocial evaluation based on the collected historical information of the client.
The facility's written procedure regarding medical, drug/alcohol and personal histories states these histories will be completed by the fifth counseling session. Based on a review of client records, the facility failed to document medical, drug/alcohol and personal histories no later than the fifth counseling session in client records # 3, 4, 5, 6 and 7.
Client # 3 was admitted into treatment on June 15, 2011. The medical, drug/alcohol and personal histories were due to be completed no later than the fifth counseling session which was conducted on July 20, 2011. The medical, drug/alcohol and personal histories were not documented until July 27, 2011.
Client # 4 was admitted into treatment on February 15, 2011. The medical, drug/alcohol and personal histories were due to be completed no later than the fifth counseling session which was conducted on April 5, 2011. The medical, drug/alcohol and personal histories were not documented until May 16, 2011.
Client # 5 was admitted into treatment on May 10, 2011. The medical, drug/alcohol and personal histories were due to be completed no later than the fifth counseling session which was conducted on July 25, 2011. The medical, drug/alcohol and personal histories were not documented until August 4, 2011.
Client # 6 was admitted into treatment on March 15, 2011. The medical, drug/alcohol and personal histories were due to be completed no later than the fifth counseling session which was conducted on May 31, 2011. The medical, drug/alcohol and personal histories were not documented until June 15, 2011.
Client # 7 was admitted into treatment on April 27, 2011. The medical, drug/alcohol and personal histories were due to be completed no later than the fifth counseling session which was conducted on June 21, 2011. The medical, drug/alcohol and personal histories were not documented until July 21, 2011.
The project and facility directors were interviewed throughout the licensing inspection. The facility director confirmed that the client histories were not completed by the fifth session, as required by facility policy. The project and facility directors both confirmed the procedure states staff will complete the psychosocial evaluation prior to the medical, drug/alcohol and personal histories. The project director reported this procedure will be revised.
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Plan of Correction
The facility director has updated our current policy that all intake, psycho/socials will be completed by the following timeline of sessions:
Policy has been changed to reflect that counselors will complete the preliminary treatment plan by the first session, intake and psychosocial by the fifth session of opening. All staff were trained on new policy by the facility direction during their weekly supervision the week of September 6, 2011. The facility director will monitor client records on a monthly basis to ensure staff are documenting this information according the new policy |