INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 23, 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 and Children's Aid Society 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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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 obtain an informed and voluntary consent which included purpose of disclosure in one of seven applicable records reviewed.
Client #4 was admitted April 29, 2024 and still a current client. A release of information was signed to a personal contact which did not include purpose of disclosure on April 29, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 19, 2023 licensing inspection.
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Plan of Correction
Program Director reviewed this deficiency with the Clinical Supervisor on September 27 and then with all clinical staff on September 30 during a staff meeting. Program Director reviewed requirements for releases of information, created a check list for all clinical staff to follow when filling out a release of information, and had all clinical staff sign an acknowledgement of understanding following thirty (30) minutes of training on this process.
Beginning September 30, 2024, clinical supervisor and program director will review all releases of information to ensure compliance. If any part of the required documentation is missing clinical staff will be redirected to complete a new release of information at the client's next individual session.
Client #4 completed a new release of information and identified the purpose of disclosure as emergency contact on October 10, 2024.
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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 complete initial treatment plans in a timely fashion according to agency policy and procedure manual in four out of seven records.
According to agency policy and procedures, the preliminary treatment plan is completed at intake, initial treatment plan is completed by 30 days, and all additional updates are done every 60 days thereafter.
Client #4 was admitted April 29, 2024 and still a current client. Client #4 preliminary treatment plan was completed on April 29, 2024 and initial treatment plan was due by May 29, 2024 but not completed until May 31, 2024.
Client #5 was admitted May 24, 2024 and still a current client. Client #5 preliminary treatment plan was completed on May 24, 2024 and initial treatment plan was due by June 23, 2024 but not completed until June 28, 2024.
Client #6 was admitted June 3, 2024 and still a current client. Client #6 preliminary treatment plan was completed on June 3, 2024 and initial treatment plan was due by July 3, 2024 but not completed until July 16, 2024.
Client #7 was admitted April 25, 2024 and still a current client. Client #7 preliminary treatment plan was completed on April 25, 2024 and initial treatment plan was due by May 25, 2024 but not completed until May 31, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 19, 2023 licensing inspection.
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Plan of Correction
Program Director discussed this deficiency with the Chief Executive Officer during licensing and then all clinical staff during the staff meeting on September 30, 2024. Program Director will meet with the EHR administrator to implement trigger notifications for treatment plans one (1) week prior to their due date. For all initial treatment plans clinical staff will schedule to complete them twenty-three (23) days after intake. The EHR Administrator and Program Director will implement this trigger notification by November 30, 2024.
Program Director and Clinical Supervisor will also review all upcoming treatment plans with clinical staff during weekly supervisions. Clinical Supervisor will maintain an excel spreadsheet identifying the due dates of all treatment plans for staff to track.
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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 complete treatment plan updates at least every 60 days in three of seven records reviewed.
Client #1 was admitted February 1, 2024 and discharged July 12, 2024. A treatment plan was completed on March 7, 2024 and an update was due by May 6, 2024 but not completed until June 13, 2024.
Client #5 was admitted May 24, 2024 and still a current client. A treatment plan was completed on June 28, 2024 and an update was due by August 27, 2024 but not completed until September 5, 2024.
Client #6 was admitted June 3, 2024 and still a current client. A treatment plan was completed on July 16, 2024 and an update was due by September 14, 2024 but not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 19, 2023 licensing inspection.
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Plan of Correction
Program Director discussed this deficiency with the Chief Executive Officer during licensing and then all clinical staff during the staff meeting on September 30, 2024. Program Director will meet with the EHR administrator to implement trigger notifications for treatment plans one (1) week prior to their due date. clinical staff will schedule to complete treatment plan updates fifty-three (53) days after previous treatment plan was completed. The EHR Administrator and Program Director will implement this trigger notification by November 30, 2024.
Program Director and Clinical Supervisor will also review all upcoming treatment plans with clinical staff during weekly supervisions. Clinical Supervisor will maintain an excel spreadsheet identifying the due dates of all treatment plans for staff to track.
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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 case consultations in three of seven applicable records.
The facility's policy and procedure manual states a case consultation must be completed 90 days following admission and then every 60 days thereafter.
There were no case consultations found in the following client records.
Client #1 was admitted February 1, 2024 and discharged July 12, 2024.
Client #3 was admitted May 22, 2024 and discharged September 19, 2024.
Client #6 was admitted June 3, 2024 and still a current client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director, Clinical Supervisor, and all clinical staff reviewed this deficiency during the staff meeting on September 30, 2024. Program Director reviewed policies of case consultations being completed for treatment plan updates, team meetings, change of level of care, and discharge. Program Director and Clinical Supervisor will implement clinical review of these events during weekly supervisor to ensure all clinical staff are completing case consultations when treatment plan updates are completed.
Clinical Supervisor and Program Director will review all other active clients and follow up with clinical staff on identified case consultations that need to be completed.
All case consults that were identified missing will be completed by October 31, 2024
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