INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25-26, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Progressive Medical Specialists, 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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704.12(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, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on July 25-26, 2013. The form listed one clinical supervisor , five counselors and two counselor assistants. The facility has an exception for reduced caseloads. However, two counselors listed as having a reduced caseload did not qualify as they have not been employed with the project for a period of one year.
Employee # 3 was hired on December 10, 2012 as a counselor. The counselor was listed as having 43 active clients. As the counselor was not eligible for a reduced caseload due to the length of employment at the project, the employee had a FTE of 43:1.
Employee # 9 was hired on October 2, 2012 as a counselor. The counselor was listed as having 44 active clients. As the counselor was not eligible for a reduced caseload due to the length of employment at the project, the employee had a FTE of 44:1.
The Project/Facility Director was interviewed on July 26, 2013 and confirmed the findings.
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Plan of Correction
Due to an open counselor position we were not able to be in compliance with the 35:1 client counselor ratio as noted in the inspector's observation, (however, we were able to ensure that all clients were receiving counseling time.)We have since hired and completed orientation training with a new staff member. Now that this position is filled with qualified a staff member we are able to ensure that all counselors remain at the 35:1 client counselor ratio. All caseloads have been adjusted to ensure compliance with standard.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of financial statements, the project failed to complete an audit by year's end, December 31, 2012.
The findings include:
The financial statements for year ending December 31, 2012 were reviewed on July 23-24, 2013. The project failed to complete an audit by year's end, December 31, 2012. The financial review for year ending December 31, 2012 included a letter from the accounting firm. The letter stated that they reviewed the statements of revenue and the expenses and the retained earnings for the year ending December 31, 2012. We have not audited or reviewed the accompanying financial statements, and accordingly do not express an opinion or any other form of assurances in them.
The Project/Facility Director was interviewed on July 24, 2013 and confirmed the findings.
This is a repeat citation. The facility was previously cited for noncompliance with this standard on 7/20/12 and 7/14/11.
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Plan of Correction
Currently the facility has requested an exception to the financial audit standard. We are still waiting for response to our request. If we receive the exception we will maintain documents regarding the exception with our copies of our licenses, certifications and other approved exceptions for review during any type of inspection at the facility.
If we are not approved for the exception, the board of directors will be notified of the denial and informed that we are required to complete the financial audit.
We would need to have the audit completed by December 1, 2013. Thereafter, a financial audit will be scheduled to be completed no later than May 31, every year. |