INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 18, 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 September 4, 2012. 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
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 September 4, 2012. 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.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, a psychosocial evaluation of the client in one of one client record reviewed.
Client # 1 was admitted on September 25, 2024 and was still active at the time of the inspection. There was no psychosocial evaluation 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
Based on a review of client records, the facility failed to document, as part of their intake and admission process, a psychosocial evaluation of the client in one of one client record reviewed.
Client # 1 was admitted on September 25, 2024 and was still active at the time of the inspection. There was no psychosocial evaluation documented in the record as of the date of the inspection. Clinical supervisor will ensure psychosocial evaluation is in client #1 record by 2/28/2025. This will be implemented by regular file checks and training of staff. Facility will be compliant by February 28, 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 one of one client record reviewed.
Client # 1 was admitted on September 25, 2024 and was still active at the time of the inspection. The individual treatment plan was completed by facility staff on October 1, 2024; however, there was no documentation indicating the treatment 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 one of one client record 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 one of one client record reviewed.
Client # 1 was admitted on September 25, 2024 and was still active at the time of the inspection. The individual treatment plan, completed by facility staff on October 1, 2024, did not include documentation of the type and frequency of treatment services that were to be 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 one of one client record 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. |