INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 9, 2014 - September 11, 2014 by staff from the Division of Drug and Alcohol 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:
|
Plan of Correction
|
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
|
Observations
Based on a review of personnel records, the facility failed to document an annual performance evaluation in one of five applicable personnel records reviewed.
The findings include:
Five personnel records requiring documentation of an annual performance evaluation were reviewed on 9/9/2014. The facility failed to document an annual performance evaluation in personnel record # 1.
Employee # 1 was hired as the project director on 1/22/2008. Employee # 1 ' s last annual performance evaluation was completed on 7/25/2012.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director (Employee #1) will have her Employee performance evaluation completed and reviewed by the governing board's personnel committee by 10/31/14. In the future, the Facility Director will ensure that all Employee performance evaluations including her own are done on a yearly basis. Effective January 2015, as a standard procedure, all agency performance evaluations will be completed by February 28th yearly. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on the review of client records, the project failed to ensure that counseling services were provided according to the individual treatment plan in seven of ten client records reviewed.
The findings include:
Ten client records were reviewed for the provision of providing counseling services in accordance with treatment plans. The project failed to ensure that clients received counseling services according to the client's individual treatment plan in client records # 1, 3, 4, 5, 6, 7 and 8.
Client record # 1 contained a treatment plan dated 7/3/2014 that identified the counseling services to be provided as an individual session one time per week. The record did not contain documentation of any individual sessions during the week of 8/11/2014 - 8/15/2014.
Client record # 3 contained a treatment plan dated 5/20/2014 that identified the counseling services to be provided as an individual session one time per week. The record did not contain documentation of any individual sessions during the weeks of 8/4/2014 - 8/8/2014 and 8/18/2014 - 8/22/2014.
Client record # 4 contained a treatment plan dated 8/25/2013 that identified the counseling services to be provided as an individual session one time per week. The record did not contain documentation of any individual sessions during the weeks of 10/7/2014 - 10/11/2014 and 10/14/2014 - 10/18/2014.
Client record # 5 contained a treatment plan dated 10/11/2013 that identified the counseling services to be provided as an individual session one time per week. The record did not contain documentation of any individual sessions during the weeks of 11/4/2013 - 11/8/2013, 11/11/2013 - 11/15/2013 and 11/18/2013 - 11/22/2013.
Client record # 6 contained a treatment plan dated 11/24/2013 that identified the counseling services to be provided as an individual session one time per week. The record did not contain documentation of any individual sessions during the weeks of 11/25/2013 - 11/29/2013, 12/9/2013 - 12/13/2013, 12/16/2013 - 12/20/2013 and 12/23/2013 - 12/27/2013.
Client record # 7 contained a treatment plan dated 10/4/2014 that identified the counseling services to be provided as an individual session one time per week. The record did not contain documentation of any individual sessions during the week of 11/25/2013 - 11/29/2013.
Client record # 8 contained a treatment plan dated 11/18/2013 that identified the counseling services to be provided as an individual session one time per week. The record did not contain documentation of any individual sessions during the weeks of 12/16/2013 - 12/20/2013 and 12/23/2013 - 12/27/2013.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All clinical staff including the Facility Director and Program Director discussed via individual supervision and at our D&A staff meeting held on Monday, September 22,2014 the citation of each identified charts and plans of correction which includes: 1)Each counselor will document in the charts (ROC)Report of Contact the reason for not providing counseling services to the consumer, counseling offered for that week or what the counseling service indicates with primary counselor or another counselor (accepted or declined). 2)Weekly random chart checks by clinical supervisor or Facility Director to ensure info is being documented. 3) Add to 30,60, 90 day chart check forms a check off process that the proper service is being offered is in the charts. If the documentation is not present the primary counselor will make appropriate changes. |