INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 29, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Family Service Association of Bucks County 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 complete a written individual training plan for each employee, appropriate to that employee's skill level with input from both the employee and the supervisor, in ten of ten personnel records reviewed.
In each personnel record reviewed, there was no individual training plan documented for the facility's current training year as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility transitioned from iSolved HR software system to ADP HR software system this year, which caused a lapse in completion of individualized training plans.
On 10/8/24 a new Annual Performance Review (which includes individualized training plans) was debuted to management staff. On 11/22/24, an all staff meeting was held to inform that these new Annual Performance Reviews (which include individualized training plans) are active in ADP and will be completed for all employees annually on their hire date.
An electronic reminder will be sent out from ADP via email for all performance evaluations, which include individual training plan. During weekly clinical supervisor meeting, any upcoming performance evaluations, which include individual training plan, will be review by Associate Director of Clinical Services to ensure completion. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health-related topics training within the regulatory timeframe in one of one applicable personnel record reviewed.
Employee # 7 was hired as a counselor on October 13, 2023 and was due to have the HIV/AIDS training and the TB/STD training completed no later than October 13, 2024. There was no documentation, in the record, indicating the HIV/AIDS training and the TB/STD training were completed as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A new position was created and staffed at Family Service "Quality Improvement and Training Specialist" to assist in monitoring training completion requirements for all programs. This will ensure all trainings are completed in a timely manner.
Clinicians in need of trainings will be registered to complete trainings as they are offered. |
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 the review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training for the facility ' s July 1, 2023 through June 30, 2024 training year in one of four applicable personnel records reviewed.
Employee # 4 was hired as a counselor on June 6, 2022. In the record, there was 9.25 hours of training documented during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A new position was created and staffed at Family Service "Quality Improvement and Training Specialist" to assist in monitoring training completion requirements for all programs. This will ensure all trainings are completed in a timely manner.
On clinical supervision form, a "trainings completed" section was added so clinical supervisors can also monitor yearly trainings.
Associate Director of Clinical Services will meet with D&A clinical supervisor weekly and review trainings completed/needed. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all facility heaters were permanently mounted or installed.
At the time of the inspection, there was a portable space heater located in counseling room 118.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/30/24, an email was sent to clinician to have portable space heater removed immediately.
On 12/12/24, an outpatient meeting will be held, where all staff will be reminded that no space heaters are permitted in the building.
Facilities Maintenance Manager and Associate Director of Clinical Services will complete a monthly walk through of building/offices to ensure that no space heaters are present. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's November 2023 through September 2024 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.
The facility's hours of operation are Monday through Wednesday from 8:30AM to 8:00PM and Thursday and Friday from 8:30AM to 5:00PM. All of the fire drills reviewed were conducted during the morning hours. There were no drills conducted during the facility's afternoon or evening hours of operation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Information was discussed with Facilities Maintenance Manager, who manages facility fire drills.
Fire drills will be conducted by Facilities Maintenace Manager at different times during the day to cover hours of operation. Associate Director of Clinical Services will review the fire drills monthly to ensure they are being completed at different times (morning, afternoon, and evening) throughout the year. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to ensure the completion of annual written individual staff performance evaluations, which shall be reviewed and signed by the employee, in six of six applicable personnel records reviewed.
Employee # 1 was hired as the project/facility director on June 12, 2023. There was no individual performance evaluation, for the previous year, documented in the record as of the date of the inspection.
Employee # 3 was hired as a counselor on September 30, 2019. There was no individual performance evaluation, for the previous year, documented in the record as of the date of the inspection.
Employee # 4 was hired as a counselor on June 6, 2022. There was no individual performance evaluation, for the previous year, documented in the record as of the date of the inspection.
Employee # 5 was hired as a counselor on June 26, 2023. There was no individual performance evaluation, for the previous year, documented in the record as of the date of the inspection.
Employee # 6 was hired as a counselor on August 23, 2023. There was no individual performance evaluation, for the previous year, documented in the record as of the date of the inspection.
Employee # 7 was hired as a counselor on October 13, 2023. There was no individual performance evaluation, for the previous year, documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility transitioned from iSolved HR software system to ADP HR software system this year, which caused a lapse in completion of staff performance evaluations.
On 10/8/24 a new Annual Performance Review was debuted to management staff. On 11/22/24, an all staff meeting was held to inform that these new Annual Performance Reviews are active in ADP and will be completed for all employees annually on their hire date.
An electronic reminder will be sent out from ADP via email for all performance evaluations. During weekly clinical supervisor meeting, any upcoming performance evaluations will be review by Associate Director of Clinical Services to ensure completion. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review and a review of client records, the facility failed to maintain a recordkeeping system that allowed for the identification of clients' admission dates and discharge dates within a specific time period.
The facility was asked to provide the Department Licensing Representative with a list of their currently active, as well as their discharged clients for the timeframe covering November 17, 2023 to the date of the inspection. The client list that was provided by facility staff had admission dates and discharge dates admission which did not match the clients' dates of treatment within the facility's electronic medical record system.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A new position was created at Family Service, "Outpatient Program Manager," which will be staffed as of 12/2/24. Part of this role includes assisting with the electronic medical records and maintaining accurate reports from Credible and Family Service. This will ensure accurate data is pulled with correct admission/discharge/programs. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in five of six applicable client records reviewed.
Client # 3 was admitted on April 9, 2024 and was active at the time of inspection. The comprehensive treatment plan was completed on April 9, 2024 and the first update was due no later than June 9, 2024; however, the update was not completed until June 27, 2024.
Client # 4 was admitted on February 14, 2024 and was discharged on July 29, 2024. A treatment plan update was completed on April 12, 2024 and the next update was due no later than June 12, 2024; however, the update was not completed prior to the client's discharge.
Client # 5 was admitted on October 20, 2023 and was discharged on August 6, 2024. A
treatment plan update was completed on January 3, 2024 and the next update was due no later than March 3, 2024; however, the update was not completed until March 29, 2024. Additionally, a treatment plan update was completed on March 29, 2024 and the next update was due no later than May 29, 2024; however, the update was not completed until June 7, 2024.
Client # 6 was admitted on July 1, 2023 and was discharged on May 30, 2024. A treatment plan update was completed on October 23, 2023 and the next update was due no later than December 23, 2023; however, the update was not completed until March 21, 2024. Additionally, a treatment plan update was completed on March 21, 2024 and the first update was due no later than May 21, 2024; however, the update was not completed prior to the client's discharge.
Client # 7 was admitted on September 1, 2023 and was discharged on September 19, 2024. A treatment plan update was completed on April 22, 2024 and the next update was due no later than June 22, 2024; however, the update was not completed until July 18, 2024.
This is a repeat citation from the January 10, 2020, November 19, 2020, December 16, 2021, December 12, 2022, and November 17, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan timeliness will be addressed during outpatient staff meeting on 12/12/24.
In addition, supervisors began completing newly updated chart reviews to monitor timeliness of treatment plan completion. |
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 a maintain a complete client record on an individual, which is to include the documentation of case consultation notes, in four of seven client records reviewed.
Client # 1 was admitted on July 24, 2024 and was active at the time of inspection. There was no case consultation note documented in the record at the time of the inspection.
Client # 2 was admitted on July 2, 2024 and was active at the time of inspection. There was no case consultation note documented in the record at the time of the inspection.
Client # 3 was admitted on April 9, 2024 and was active at the time of inspection. There was no case consultation note documented in the record at the time of the inspection.
Client # 4 was admitted on February 14, 2024 and was discharged on July 29, 2024. There was no case consultation note 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
Case consult timeliness will be addressed during outpatient staff meeting on 12/12/24.
In addition, supervisors began completing newly updated chart reviews to monitor timeliness of case consult completion.
Client 1 and client 4 have been discharged. A case consult has been completed for clients 2 & 3 and will continue to be completed moving forward. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing treatment plan updates within the regulatory timeframe was submitted and approved by the Department for the January 10, 2020, November 19, 2020, December 16, 2021, December 12, 2022, and November 17, 2023 annual licensing inspections. Not completing treatment plan updates within the regulatory timeframe was again found to be a deficiency in the October 29, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Assurance has compiled a list of all facility POC. Associate Director of Clinical Services will meet with her quarterly to review POC and ensure all plans are being completed effectively.
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