INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 27-28, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, FamilyLinks, 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(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of administrative information and the facility ' s policy and procedure, the facility failed to include, in their staff development program policy and procedures, the specific timeframes for completion and who is responsible for the completion of the components.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Comprehensive staff development policy has been created to include specific timeframes and who is responsible. Staff development policy indicates quarterly evaluations of overall training plan. Staff will complete an individualized training plan at hire, 1 year after hire and then every calendar year. Individual staff training plans have been updated to include timeframes and most recent required training courses. Staff will complete training feedback survey after every training. All staff will be trained on these new documents at next Outpatient Substance Use meeting on 6/22/22 by Program Managers |
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 review of The Staffing Requirements Facility Summary Report, the FTE counselor caseload for two counselors in the outpatient program exceeded 35 active clients.
Staff #4 was hired as a Counselor on June 7, 2021 and was still in this position at the time of the inspection. Staff #4 was reported to have 25 hours per week devoted to their 32 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 25/37.5 = .66 (FTE); 32/.66 = 48.48, which equals to a client/counselor ratio of 48:1.
Staff #6 was hired as a Counselor on December 7, 2021 and was still in this position at the time of the inspection. Staff #6 was reported to have 15 hours per week devoted to their 23 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 15/37.5 = .4 (FTE); 23/.4 = 57.5, which equals to a client/counselor ratio of 57:1.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facilities hours of operation 37.5. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 25, 2021 annual licensing inspection.
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Plan of Correction
Staff #4 now has 21 D&A clients on their caseload. Staff #6 now has 10 D&A clients on their caseload. Caseload numbers and number of hours per week spent with active D/A clients will continue to monitored at least monthly by Program Managers to ensure compliance |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the facility's fire drill log for the months of March 2021 through March 2022, the facility failed to prepare alternate exit routes to be used during fire drills. The front door was the lone fire exit for all documented fire drills except for October 14, 2021, when no exit route was indicated on the fire drill report.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff conducting fire drills have been trained on alternative routes and will begin use of alternative exit routes starting in July 2022. Program Manager to review fire drills logs to ensure compliance. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative information, the facility failed to document a 2020-2021 annual report.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility will provide 2020-2021 annual report upon completion in June to meet compliance standard.
Waivers will be submitted in advance for 2022-2023 and 2023-2024 financial reports while the report cycle is adjusted. The facility will submit draft annual reports during these two years to ensure information is submitted.
Person Responsible: Director, COO
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative information, the facility failed to document an annual financial audit for fiscal year 2020-2021.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility will provide 2020-2021 financial audit report upon completion in June to meet compliance standard.
Due to the preparation schedule of financial audits, it will take two cycle years to fully be on schedule per state requirement. Waivers will be submitted in advance for 2022-2023 and 2023-2024 financial audits to maintain compliance while the audit cycle is adjusted. The facility will work with Finance Department to obtain annual financial audit for all future audits.
Responsible Person: Director, COO
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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 facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in two of six client records reviewed.
Client #1 was admitted on August 17, 2021 and was discharged on February 3, 2022. There was no release of information signed by the client for the funding source.
Client #3 was admitted on August 30, 2021 and was discharged on November 30, 2021.
There was no release of information signed by the client for the funding source.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 25, 2021 annual licensing inspection.
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Plan of Correction
Staff retraining on Releases of Information was completed on 5/24/22 to specify Releases within 5 points for funding sources. Compliance department to attend staffing meeting on 6/22/22 for further training and deployment of revised Release of Information. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure compliance of all current and future clients. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document a release of information within the parameters of 255.5 in three of six records reviewed.
Client #2 was admitted on December 29, 2021 and was discharged on March 28, 2022. Releases of information to a funding source and to a government agency were both signed by the client on December 21, 2022, and both allowed for the disclosure of the " assessment, physician orders, discharge / transfer summary, progress/psychotherapy notes, continuing care plan, psychosocial evaluation, psychiatric/psychological evaluation, medication records, nursing/medical records, treatment plan, and service notes/journal " .
Client #5 was admitted on January 3, 2022 and was still active at the time of the inspection. Release of information to another agency was signed by the client on April 22, 2022 and allowed for the disclosure of the discharge summary.
Client #6 was admitted on February 7, 2022 and was still active at the time of the inspection. Releases of information to another agency and to a government agency were both signed by the client on January 31, 2022 and allowed for the disclosure of the " assessment, physician orders, discharge / transfer summary, progress/psychotherapy notes, continuing care plan, psychosocial evaluation, psychiatric/psychological evaluation, medication records, nursing/medical records, treatment plan, educational information and service notes/journal " .
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Staff retraining on Releases of Information was completed on 5/24/22 to specify the information disclosed. Compliance department to attend staffing meeting on 6/22/22 for further training and deployment of revised Release of Information. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure all current and future clients remain compliant. |
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 of client records, the facility failed to document a purpose of disclosure on the release of information form in one of six records.
Client # 4 was admitted on July 6, 2021 and discharged on October 1, 2021. A release of information to a government agency was signed on May 18, 2021 but did not indicate a purpose of disclosure.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Staff retraining on Releases of Information was completed on 5/24/22 to specify necessity of purpose of disclosure on valid Releases of Information. Compliance department to attend staffing meeting on 6/22/22 for further training and deployment of revised Release of Information. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure all current and future client are compliant. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on client records reviewed, the facility failed to include the dated signature of the witness on the release of information form in one of six records.
Client #5 was admitted on January 3, 2022 and was still active at the time of the inspection. A release of information to an individual was signed by the client on December 27, 2021 and did not have a dated signature of the witness.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Staff retraining on Releases of Information was completed on 5/24/22 to specify necessity of witness signatures and dates on valid Releases of Information. Compliance department to attend staffing meeting on 6/22/22 for further training and deployment of revised Release of Information. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure all current and future clients will be compliant. |
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 administrative information and the client records, the facility failed to include ethnicity, handicap, religion, and marital status in the client rights for non-discrimination. This was missing in the policy and procedure, and in the written acknowledgement in six of six client records.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Client rights document has been updated in accordance with 709.30 (2) to include no discrimination based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. Client right will be signed by all clients at intake and on an annual basis. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure completion. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of administrative information and the client records, the facility failed to include all components of the client ' s right to inspect their record in six of six records.
The electronic release of information, which includes client rights, is missing the client ' s right of record inspection. The facility ' s handbook does allow this right, but the facility failed to document each client was informed of the right for the temporary removal of portions of the record. The written acknowledgement in the client records did not include the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Current documentation allows for the therapist to remove the information.
The policy indicates only the Project Director may temporarily remove portions of the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client rights document has been updated in accordance with 709.30 (3) to include client's right to inspect their records and potential removal of portions. Client right will be signed by all clients at intake and on an annual basis. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure completion. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to document each client was informed of the client rights to appeal a decision limiting access to their records to the director in six of six client records.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Client rights document has been updated in accordance with 709.30 (4) to include a client's right to appeal a decision limiting their access to their records. Client right will be signed by all clients at intake and on an annual basis. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure completion. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to document each client was informed of the client rights to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records in six of six client records.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Client rights document has been updated in accordance with 709.30 (5) to include client's rights to request corrections. Client right will be signed by all clients at intake and on an annual basis. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure completion. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document each client was informed of the client rights to submit rebuttal data or memoranda to their own records in six of six client records.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Client rights document has been updated in accordance with 709.30 (6) to include client's rights to submit a rebuttal. Client right will be signed by all clients at intake and on an annual basis. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure completion. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on discussions with facility staff and an administrative information review, the facility failed to file a written unusual incident report with the Department within 3 business days following an event at the facility requiring the presence of police, fire, or ambulance personnel. An incident occurred on February 24, 2022 where police and ambulance were called to the facility; however, this was not reported to the Department
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Current Sr. Program Manager is now registered and able to submit incident reports electronically. Prior incident report was submitted and will continue to submitted in the future. |
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 review and update the treatment and rehabilitation plans at least every 60 days in three of three applicable records.
Client #1 was admitted on August 17, 2021 and discharged on February 3, 2022. A treatment plan was done on November 4, 2021, so a treatment plan update was due by January 4, 2022. The treatment and rehabilitation plan update was missing in the client record.
Client #3 was admitted on August 30, 2021 and discharged on November 30, 2021. A treatment plan was done on September 15, 2021, so a treatment plan update was due by November 15, 2021. The treatment and rehabilitation plan update was missing in the client record.
Client # 5 was admitted on January 3, 2022 and was still active at the time of the inspection. A treatment plan was done on January 21, 2022. A treatment plan update was due to be completed by March 21, 2022, and was done on April 22, 2022. The treatment and rehabilitation plan update in the client record was reviewed and updated beyond 60 days.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 25, 2021 annual licensing inspection.
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Plan of Correction
Current policies and procedures require treatment plan reviews every 60 days. In these client records, policy was not followed. A retraining of outpatient substance use staff was completed on 5/24/22 on timely completion of treatment plans. On a monthly basis, Program Managers will send out notifications for upcoming expiring treatment plans. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure all current and future clients are compliant. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to include follow-up information relative to the client ' s involvement with the project in two of four applicable records.
Client #1 was admitted on August 17, 2021 and discharged on February 3, 2022. Follow-up information relative to the client ' s discharge was missing in the client record.
Client #3 was admitted on August 30, 2021 and discharged on November 30, 2021. Follow-up information relative to the client ' s discharge was missing in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Current policies and procedures require at least two follow up calls. In these client records, policy was not followed. A retraining of outpatient substance use staff will be completed on 6/22/22 on importance of followup calls. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure all current and future clients are compliant with followup calls. |