INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 19, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Service Foundation, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on the review of personnel records, the facility failed to ensure that the facility director met the qualifications for the position in one of one records reviewed.
Five personnel records were reviewed on January 19, 2017 one of which was identified as the personnel record for the facility director. Employee #2 was hired as the facility director on March 16, 2016. A review of the employee's college transcripts indicated that he had a Master's Degree in Philosophy, which is not a qualifying degree for the position.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a result of the inspection, the Facility Director will no longer hold this position. The Project Director will assume the role of the Facility Director. This change will be effective as of February 24, 2017. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based upon staff interviews and a physical plant inspection conducted on January 19, 2017, the facility's policy and procedure of informing clients of their rights failed to ensure that clients would be informed of all of their rights.
The procedure for informing clients of their rights was to show the clients the posted client rights and to have clients sign off that they were informed of those rights. However, the posted client rights policy was missing the following verbiage: creed, marital status and ethnicity.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will ensure that the client rights form includes: The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. This is changed to include regulation 709.30 #2. At the time of the inspection clients were not being properly informed of their rights as stated in the aforementioned regulation. The clinical supervisors will supervise the counselors to implement this change starting on 3/1/17. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on the review of the facility's policy and procedure manual on January 19, 2017, the facility failed to develop and implement policies and procedures to respond to the following unusual incidents:
709.30 (a)
(1)physical assault or sexual assault by staff or a client
(2)selling or use of illicit drugs on the premises
(3)death or serious injury due to medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services
(5) theft, burglary, break-in or similar incident at the facility
(6) event at the facility requiring the presence of ambulance personnel
(7) structural damage to the facility
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will be responsible for creating a policy that specifically states the reporting of unusual incidents as outlined in 709.34 (a). This policy will be created and supported by the board of directors by 4/18/17. We will send the policy by 4/19/17 to the department. |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
Based on the review of the facility's policy and procedure manual on January 19, 2017, the facility failed to develop and implement policies and procedures that included:
709.34 (b)
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will be responsible for creating a policy that specifically states the reporting of unusual incidents as outlined in 709.34 (b). This policy will be created and supported by the board of directors by 4/18/17. We will send the policy by 4/19/17 to the department. |
709.14(a) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
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Observations
Based on interviews with facility staff, treatment services were being provided outside of the licensed treatment facility.
28 Pa. Code 701.1. General definitions defines a facility as - The physical location in which ongoing, structured and systematic drug and alcohol services are delivered.
28 Pa. Code 709.1 (a) States - This chapter establishes the procedures for the issuance of a license by activity to free-standing drug and alcohol treatment facilities. The term, facility, applies to the physical location from which drug and alcohol services are provided.
Facility staff stated during an interview at the time of the inspection, that individual and family counseling services were being provided in the clients' homes.
This was discussed with facility staff during the inspection.
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Plan of Correction
At this time all group sessions will be conducted in the facility. Individual and family sessions as needed will be conducted in the facility. We will write an exception request to return to conducting individual and family sessions in the home. This will be in effect starting 3/10/17. We will submit the exception request by 3/24/17. If our request is denied, we will comply prescriptively. |