INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 9, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure a written individual training plan was developed annually for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor in one of four personnel records reviewed.
Employee # 3 was hired as a counselor on July 1, 2023. There was no individual training plan, for the current training year, documented in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee # 3 was hired as a counselor on July 1, 2023. There was no individual training plan, for the current training year, documented in the personnel record at the time of the inspection. Clinical supervisor will ensure a written individual training plan is developed annually for each employee for the current training year. This will be done through regular personnel file checks. Facility will be compliant by February 28, 2025. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the project failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 4 was admitted on March 15, 2024 and was discharged on July 29, 2024. There was evidence of disclosures to the funding source for services completed on March 7, 2024, March 15, 2024, and March 21, 2024; however, the funding source consent to release information form was not signed by the client until April 13, 2024. Additionally, there was evidence of disclosures to a parole officer on March 7, 2024; however, the parole officer consent to release information form was not signed by the client until April 13, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client # 4 was admitted on March 15, 2024 and was discharged on July 29, 2024. There was evidence of disclosures to the funding source for services completed on March 7, 2024, March 15, 2024, and March 21, 2024; however, the funding source consent to release information form was not signed by the client until April 13, 2024. Additionally, there was evidence of disclosures to a parole officer on March 7, 2024; however, the parole officer consent to release information form was not signed by the client until April 13, 2024. Clinical supervisor will ensure the facility will obtain an informed and voluntary consent to release information form prior to the disclosure of information. This will be done through regular file checks and staff training. Facility will be compliant by February 28, 2025. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review client records, the facility failed to document the purpose of the disclosure on a release of information form in one of seven client records reviewed.
Client # 1 was admitted on May 23, 2024 and was still active at the time of the inspection. The release of information form to an emergency contact was signed by the client on May 23, 2024, but the form did not include documentation of the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility failed to document the purpose of the disclosure on a release of information form in one of seven client records reviewed. Clinical supervisor will ensure the purpose of the disclosure on a release of information form is documented in the client record. This will be implemented by regular file checks and training of staff. Facility will be compliant by February 28, 2025. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake procedures, a preliminary treatment and rehabilitation plan in three of three applicable client records reviewed.
Client # 1 was admitted on May 23, 2024 and was still active at the time of the inspection. There was no preliminary treatment plan documented in the record at the time of the inspection.
Client # 4 was admitted on March 15, 2024 and was discharged on July 29, 2024. There was no preliminary treatment plan documented in the record at the time of the inspection.
Client # 5 was admitted on February 7, 2024 and was discharged on April 24, 2024. There was no preliminary treatment plan documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on a review of client records, the facility failed to document, as part of their intake procedures, a preliminary treatment and rehabilitation plan in three of three applicable client records reviewed. Clinical supervisor will ensure a preliminary treatment and rehabilitation plan is documented in the client record. This will be implemented by regular file checks and training of staff. Facility will be compliant by March 31, 2025. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to ensure individual treatment and rehabilitation plans were developed with the client in seven of seven client records reviewed.
Client # 1 was admitted on May 23, 2024 and was still active at the time of the inspection. The individual treatment plan was completed by staff on June 5, 2024; however, there was no documentation indicating the plan was developed with the client.
Client # 2 was admitted on June 25, 2024 and was still active at the time of the inspection. The individual treatment plan was completed by staff on June 25, 2024; however, there was no documentation indicating the plan was developed with the client.
Client # 3 was admitted on July 25, 2024 and was still active at the time of the inspection. The individual treatment plan was completed by staff on July 30, 2024; however, there was no documentation indicating the plan was developed with the client.
Client # 4 was admitted on March 15, 2024 and was discharged on July 29, 2024. The individual treatment plan was completed by staff on April 2, 2024; however, there was no documentation indicating the plan was developed with the client.
Client # 5 was admitted on February 7, 2024 and was discharged on April 24, 2024. The individual treatment plan was completed by staff on February 25, 2024; however, there was no documentation indicating the plan was developed with the client.
Client # 6 was admitted on February 26, 2024 and was discharged on May 21, 2024. The individual treatment plan was completed by staff on February 26, 2024; however, there was no documentation indicating the plan was developed with the client.
Client # 7 was admitted on February 29, 2024 and was discharged on April 25, 2024. The individual treatment plan was completed by staff on February 29, 2024; however, there was no documentation indicating the plan was developed with the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure individual treatment and rehabilitation plans were developed with the client in seven of seven client records reviewed. The clinical supervisor will ensure the electronic client record is updated to reflect that individual treatment and rehabilitation plans are developed with the client and is documented in the care plan and/or clinical note. This will be implemented by regular file checks and training of staff. Facility will be compliant by March 31, 2025. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in seven of seven client records reviewed.
Client # 1 was admitted on May 23, 2024 and was still active at the time of the inspection. The individual treatment plan, completed by staff on June 5, 2024, did not include documentation of the type and frequency of treatment services provided to the client.
Client # 2 was admitted on June 25, 2024 and was still active at the time of the inspection. The individual treatment plan, completed by staff on June 25, 2024, did not include documentation of the type and frequency of treatment services provided to the client.
Client # 3 was admitted on July 25, 2024 and was still active at the time of the inspection. The individual treatment plan, completed by staff on July 30, 2024, did not include documentation of the type and frequency of treatment services provided to the client.
Client # 4 was admitted on March 15, 2024 and was discharged on July 29, 2024. The individual treatment plan, completed by staff on April 2, 2024, did not include documentation of the type and frequency of treatment services provided to the client.
Client # 5 was admitted on February 7, 2024 and was discharged on April 24, 2024. The individual treatment plan, completed by staff on February 25, 2024, did not include documentation of the type and frequency of treatment services provided to the client.
Client # 6 was admitted on February 26, 2024 and was discharged on May 21, 2024. The individual treatment plan, completed by staff on February 26, 2024, did not include documentation of the type and frequency of treatment services provided to the client.
Client # 7 was admitted on February 29, 2024 and was discharged on April 25, 2024. The individual treatment plan, completed by staff on February 29, 2024, did not include documentation of the type and frequency of treatment services provided to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in seven of seven client records reviewed. The clinical supervisor will ensure the electronic client record is updated to reflect the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan and is documented in the care plan. This will be implemented by regular file checks and training of staff. Facility will be compliant by March 31, 2025. |
709.93(a)(5) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of progress notes, in seven of seven client records reviewed.
The record of services, in every client record reviewed, indicated there were individual sessions and group sessions conducted during each client's treatment episode; however, there were several counseling progress notes that were not documented in every client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to maintain a complete client record, which is to include the documentation of progress notes, in seven of seven client records reviewed. The record of services, in every client record reviewed, indicated there were individual sessions and group sessions conducted during each client's treatment episode; however, there were several counseling progress notes that were not documented in every client record. Clinical supervisor will ensure the documentation of progress notes is maintained in the client record. This will be implemented by regular file checks and training of staff. Facility will be compliant February 28, 2025. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of case consultation notes, in four of four applicable client records reviewed.
Client # 1 was admitted on May 23, 2024 and was still active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 2 was admitted on June 25, 2024 and was still active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 3 was admitted on July 25, 2024 and was still active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 4 was admitted on March 15, 2024 and was discharged on July 29, 2024. There were no case consultation notes documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to maintain a complete client record, which is to include the documentation of case consultation notes, in four of four applicable client records reviewed. The clinical supervisor will ensure the electronic client record is updated to reflect the proper documentation of case consultation notes. This will be implemented by regular file checks and training of staff. Facility will be compliant by March 31, 2025 |