INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 12, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Diakon Child, Family and Community Ministries 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of the clinical supervisor's personnel record, the facility failed to document monthly meetings with their supervisors to discuss their duties and performance for the first 6 months employment in that position.
Employee #3 was promoted to a clinical supervisor position on May 23, 2023, and was still in that position at the time of the inspection. There was no documentation available to verify that these meetings had occurred.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
704.6(e)- Employee #3 will receive weekly documented supervision beginning 6/21/24 and ending 12/20/24. Frequency of additional supervision meetings for employee #3 will be based on clinical supervisors skill level. Additional clinical supervisors hired will receive weekly documented supervision for the first 6 months and frequency of additional supervisions will be based on skill level of the clinical supervisor. |
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 the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.
Employee #4 was hired as a counselor on September 5, 2023, and was still acting in that position. Employee #4 was reported to have 37.5 hours per week devoted to their 55 clients on their caseload.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
The FTE counselor ' s caseload calculation is as follows: 37.5/37.5 = 1 (FTE); 55/1=55, which equals to a client/counselor ratio of 55:1.
Additionally, the facility ' s overall ratio exceeds the regulatory limit of 35/1.
The overall facility ratio is determined by dividing the Total Number of Hours for Active Drug and Alcohol Clients/Project Work Week. This sum is the facility ' s Counselor FTE. The total number of Active Drug and Alcohol Clients/Counselor FTE=Facility Ratio for the outpatient activity.
The Facility Ratio for the outpatient activity is calculated as follows: 96/37.5=2.56 (Counselor FTE.) 99/2.56=38.67, which equals a facility Ratio of 38/1.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
714.12 Employee #4 caseload will be examined and appropriate discharges and transfers will occur by 7/8/24 to assure that employee #4 caseload remains at ratio regulation of 35/1. Overall facility ratio will be reviewed, caseloads analyzed, and appropriate discharges will occur monthly by the facility director for overall facility ratio compliance. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Staff #7 was hired on March 11, 2024, as a counselor assistant and was still in the position as of the date of the inspection. The training was to occur no later than March 18, 2024; however, training documents noted that Staff #7 was trained on March 19, 2024.
This finding was reviewed with the facility during the inspection process.
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Plan of Correction
705.28 (e) (4) Instruction of use of fire extinguishers for new employees will occur before 7th day of employment and will be documented by facility. Supervisors responsible for the hiring and orienting new employees will be re-educated on the standards within 705.28 by 7/1/24. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the July 31, 2023, through May 21, 2024, fire drill logs the facility failed to set off the fire alarm or smoke detector during each fire drill.
The facility reported on each of the eleven fire drills completed that the alarm was not sounded.
The facility does not currently have an exemption waiver in place for this regulator requirement.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.28 (d) (7) Facility will complete waiver exemption application to DDAP by 7/11/24. If waiver is denied, facility will initiate active smoke detector alarm during each monthly fire drill. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the facilities policy and procedure manual and interviews with the facility staff, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.23 The Policy & Procedure manual will be reviewed on an annual basis by the Project Director. A signed statement indicating this review will be available for inspection. Compliance with this standard will be monitored and enforced by the Facility Director through staff meetings and supervision. |
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 on a review of facility policies, the facility failed to include of all the required client rights, including 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.
The facility ' s client rights policy " 709.91 (A1) III. (a.) did not include age, creed, sex, color, handicap, or religion.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.30 The Project Director will develop written policies and procedures on client rights which will emphasize the project will 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. The policy will be revised and in compliance by 7/1/24. These rights are reviewed with the client during the intake session. The client signs the Acknowledgement Form showing they have been notified of these rights. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in seven out of seven applicable records reviewed.
Client #1 was admitted on February 7, 2024, and was still active at the time of the inspection. The comprehensive treatment plan, completed February 26, 2024, did not document client support services.
Client #2 was admitted on March 21, 2024, and was still active at the time of the inspection. The comprehensive treatment plan, completed April 4, 2024, did not document client support services.
Client #3 was admitted on November 7, 2023, and was still active at the time of the inspection. The comprehensive treatment plan, completed November 28, 2023, did not document client support services.
Client #4 was admitted on February 2, 2024, and was discharged on May 24, 2024. The comprehensive treatment plan, completed February 22 2024, did not document client support services.
Client #5 was admitted on November 7, 2023, and was discharged on March 12, 2024. The comprehensive treatment plan, completed November 14, 2023, did not document client support services.
Client #6 was admitted on December 5, 2023, and was discharged on March 12, 2024. The comprehensive treatment plan, completed December 12, 2023, did not document client support services.
Client #7 was admitted on October 27 2023, and was active at the time of the inspection. The comprehensive treatment plan, competed November 9, 2023, did not document client support services.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.92(a)(3)
A treatment plan tracking spreadsheet was developed 6/21/24 that denotes due dates of plans on an ongoing basis. Weekly monitoring of treatment plan due dates will be conducted by each staff member and reviewed weekly during staff meeting. Progress toward compliance of treatment plan completion and monitoring will be reviewed monthly and will be the responsibility of the facility director. |
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 document the review of treatment and rehabilitation plans every sixty days in four of seven applicable client records.
Client #2 was admitted on March 21, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was documented in the client record April 4, 2024. An updated treatment plan was due no later than June 4, 2024; however, the updated treatment plan was not completed until June 6, 2024.
Client #3 was admitted on November 7, 2023, and was still active at the time of the inspection. A treatment plan update was documented in the client record on March 5, 2024. An updated treatment plan was due no later than May 5, 2024; however, the updated treatment plan was not completed until May 7, 2024.
Client #5 was admitted on November 14, 2023, and discharged on March 12, 2024. A treatment plan update was documented in the client record on January 9, 2024. An updated treatment plan was due no later than March 9, 2024; however, the updated treatment plan was not completed until March 12, 2024.
Client #6 was admitted on December 5, 2023, and discharged on March 12, 2024. A comprehensive treatment plan was documented in the client record on December 12, 2023. An updated treatment plan was due no later than February 12, 2024; however, the updated treatment plan was not completed until February 20, 2024.
This is a repeat citation from the June 14, 2023 licensing onsite renewal.
These findings were reviewed with the facility during the inspection process.
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Plan of Correction
A treatment plan tracking spreadsheet was developed 6/21/24 that denotes due dates of plans on an ongoing basis. Weekly monitoring of treatment plan due dates will be conducted by each staff member and reviewed weekly during staff meeting. Progress toward compliance of treatment plan completion and monitoring will be reviewed monthly and will be the responsibility of the facility director. |
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 document a case consultation within guidelines established by the facility's policy and procedures manual in four out of five applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed every 90 days following admission.
Client #3 was admitted on November 7, 2023, was still active at the time of the inspection. A case consultation was due to be completed by February 7, 2024; however, the initial case consultation was completed February 20, 2024.
Client #4 was admitted on February 2, 2024, and was discharged on May 24, 2024. A case consultation was due to be completed by May 2, 2024; however the initial case consultation was completed May 24, 2024.
Client #5 was admitted on November 7, 2023, and was discharged on March 12, 2024. A case consultation was due by February 7, 2024; however there was no completed case consultation docuemented in the cleint record.
Client #7 was admitted on October 27, 2023, and was still active at the time of the inspection. A case consultation was due by January 27, 2024; however, there were no completed case consultations documented in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.93 (a) Facility will comply with requirements to provide complete records including case consultations in accordance with facility's policy and procedures. The facility director will review compliance of policy on a monthly basis. |