INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 18, 2023 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 of Venango 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director and/or facility director met the qualifications for their position in one record reviewed.
Staff #2 was promoted to facility director on April 3, 2023, and did not have the required experience prior to the promotion.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director and Facility Director will review regulations and compare to Facility Director's previous experience and qualifications and receive clarification from DDAP staff regarding terminology.-started 12/1, completed 12/4
Project Director will submit additional information regarding Facility Director's experience which demonstrates compliance with regulatory requirements by 12/8/23.
In the event there is a change in the Facility Director the following will be implemented:
Document how the candidate meets the personnel requirements in the areas of supervision, program planning (utilizing definition provided by DDAP staff), and direct service. This will be completed by Project Director and Human Resources Director-this document will be created for the current Facility Director and submitted to DDAP by 12/12/23. It will be updated as needed if there is a change in the Facility Director position.
The document of qualifications will be kept in the personnel file for the Facility Director-completed by 12/12/23 and updated as needed if there is a change in the Facility Director position.
Project Director and Human Resources Director will review current Facility Director job description to ensure regulatory requirements are included. If not, the job description will be updated with the information by 12/15/23
Project Director will send copy of current Facility Director job description to DDAP by 12/15/23. |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to ensure a mechanism was used to collect feedback on completed training during the 2022-2023 training year in two of four applicable records.
Staff #2 was hired on September 28, 2015 and still a current employee. No feedback forms were submitted for the 2022- 2023 trainings completed.
Staff #4 was hired on July 7, 2014 and still a current employee. No feedback forms were submitted for the 2022-2023 trainings completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Clinical Supervisor met on November 15 to discuss the deficiencies related to staff submitting evaluations for trainings. After reviewing the policy it was determined that does not need to be changes in the policy. Clinical Supervisor also reviewed the policy with the identified staff members number 2 and 4 at this location to ensure that they submit evaluations with all trainings completed. Clinical Supervisor and Program Director will also review the policy with all staff at the next staff meeting on December 15, 2023. All staff will be informed that evaluation forms will need to be completed for all trainings and submitted to the Program Director for their training files.
Program Director will maintain a spreadsheet of submitted trainings and evaluations attached to monitor that each staff submits the evaluation with the certificate of completion.
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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 training plan for each employee annually in one of five records reviewed.
Staff #1 has been employed since January 22, 2008 and still a current employee. Staff #1 had no individual training plan for the 2023-2024 training year at the time of onsite inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Executive Director met to discuss deficiencies related to this policy. Executive Director acknowledged not completing a training plan and it was determined that no change in policy needs to occur at this time. Executive Director has also indicated stepping down as the Project Manager and is currently taking the appropriate steps for this. The incoming Project Manager has reviewed the policies on training on November 9 and has an active training plan for the 23'-24' fiscal year.
Project Manager and Program Director will review training plans during annual evaluations to ensure training plans are maintained according to policy.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director and/or facility director completed at least 12 clock hours of training annually in one of two applicable records reviewed.
Staff #1 has been employed since January 22, 2008 and still a current employee. Staff #1 completed no training hours during the facilities 2022-2023 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director met with the Executive Director regarding the deficiency in training hours for the project director. The Executive Director identified stepping down as the Project Director and on November 9 reviewed the training expectations with the incoming Project Director. No changes in policies were deemed necessary as the incoming Project Director reviewed and confirmed expectations for training.
Incoming Project Director will adhere to all required training requirements and complete a minimum of 12 hours annually moving forward. The facility director will review training progress with the project director quarterly to ensure training requirements are met within the required time frame. The Project Director will also submit all training certificates to the Facility Director to keep on site and track in the training log.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs, the facility failed to maintain a written fire drill record to include problems encountered.
Reviewed fire drill records from November 2022 through September 2023. Written fire drill log did not include problems encountered during any fire drills from November 2022 to September 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed the fire drill policy and discussed changes necessary with Clinical Supervisor and Executive Director on November 9. The fire drill logs were reviewed from this location and it was identified that whomever is facilitating the fire drill needs to document problems encountered, and if there are none they are required to indicate 'NA' in the box. All location staff were informed of this on November 9 and will document accordingly.
fire drill logs will be reviewed monthly by Program Director to ensure facilitating staff are documenting appropriately. Fire drills will be redone prior to the month end if facilitating staff do not complete required documentation.
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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 three of seven applicable records reviewed.
Client #3 was admitted on March 23, 2023 and discharged on August 21, 2023. On March 23, 2023 the client signed three releases to insurance and two separate agencies, all of which did not include purpose of disclosure on the releases of information.
Client #4 was admitted on March 7, 2023 and discharged on August 2, 2023. On March 7, 2023 the client signed three releases to insurance and two separate agencies, all of which did not include purpose of disclosure on the releases of information.
Client #6 was admitted on March 15, 2023 and still a current client. On March 23, 2023 the client signed three releases to insurance and two separate agencies, all of which did not include purpose of disclosure on the releases of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Clinical Supervisor reviewed the Release of Information documentation and identified the error. Clinical Supervisor will review with staff during staff meeting on December 15 the process of completing Releases, including the name, address, contact number, information to be released, start date, end date, expiration date, and purpose of release. Clinical Supervisor and Program Director both will be responsible for review and quality assurance as the reviewers of all releases completed by staff. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to include documentation of medical histories at intake in seven of seven records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Clinical Supervisor reviewed the policy related to medical history as well as the Electronic Health Record program utilized on November 22, 2023. It was identified that medical history can be completed through utilization of a 'Medical Profile' link in the individual's profile. Clinical Supervisor will review this process with all clinical staff and they will begin completing the medical history as part of the biopsychosocial process immediately. Clinical Supervisor and Program Director will be responsible for ensuring this is completed within the three-session timeframe of the biopsychosocial.
For all clients active during the review time, staff will complete medical history at the next scheduled individual session with the client beginning on 11/22/23, the date they were notified of this protocol. |
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 complete case consultations according to agency policy and procedure manual timeframes in three out of seven records reviewed.
Agency P&P states case consultations must be completed within the first 90 days and then 60 days thereafter.
Client #3 was admitted on March 23, 2023 and discharged on August 21, 2023. Client #3 case consultation was due by June 21, 2023 but not completed until August 21, 2023.
Client #4 was admitted on March 7, 2023 and discharged on August 2, 2023. Client #4 case consultation was due by June 5, 2023 but not completed until August 2, 2023.
Client #6 was admitted on March 15, 2023 and still a current client. Client #6 case consultation was due by June 13, 2023 but not completed until August 15, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On November 15 Clinical Supervisor and Program Director reviewed policy and identified no need to alter this policy. Clinical Supervisor reviewed the policy with the identified staff on November 16 and staff were instructed and trained on completing case consultations per requirements. Staff will maintain these records and Clinical Supervisor will monitor compliance with policy through electronic tracking.
Through electronic monitoring of services the clinical supervisor and program director will notify counselors when case consultations are required within a week prior to the due date. Clinical supervisor will review all upcoming case consultations during weekly supervision with staff to ensure these upcoming case consults are completed.
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709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a review of the physical plant, the facility failed to display telephone number conspicuously to the general public for emergency purposes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Clinical Supervisor met on November 15 and reviewed the signage posted at this location. Agency information, including name, hours of operation, and telephone number to the main office have been posted on the front door to the building services are provided in.
Clinical Supervisor has posted an updated notification that includes the telephone number of the main office. The requirement for a telephone number will be reviewed with all facility staff during monthly reviews and prior to any changes of signage, revisions will be approved by program director to ensure compliance. |