INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 7, 2025 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that at least one person trained in CPR and first aid is onsite during project's working hours.
Employee #3 was hired on October 9, 2024 as a counselor and was still in the position as of the date of the inspection. He has first aid training dated April 23, 2023 but does not have current CPR certification.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
704.11c2 The Facility Director will meet with Clinical Directors and Human Resources to review 704.11c standard and compliance requirements. The Facility Director and Human Resources will track training requirements; The Facility Director will track training requirements and completion through yearly training plans and will be reviewed with clinical staff. This will be in compliance effective 6/16/2025. Compliance with this standard will be enforced and monitored by the Facility Director and Diakon Human Resources Department through compliance reviews. |
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 the June, 2024 through April, 2025 fire drill logs during the inspection, the facility failed to document the exit route utilized at the time of the drill during the October, 2024 and April, 2025 drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
705.28d4 The Facility Director will meet with Clinical Directors, clinical staff and administrative support staff to provide education on 705.28d4 standard and proper documentation for fire drills. This will be done through staff training, staff meetings, and supervisions. The Facility Director will revise the fire drill logs to ensure that details of the fire drill is accurately documented. This will be in compliance by 6/1/2025. Compliance with this standard will be enforced and monitored by the Facility Director through monthly fire drill log review and ongoing staff training. |
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 a review of fire drill logs from June, 2024 through April, 2025, the facility failed to prepare alternative exit route to be used during fire drills, as all drills utilized the same exit route, the front door.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
705.28d5 The Facility Director will meet with Clinical Directors, clinical staff, and administrative staff to review 705.28b5 and to educate them of Diakon's emergency exits and emergency preparedness plan. The Facility Director will revise fire drill logs to ensure that details of fire drill is accurately documented. This will be in compliance effective 6/1/2025. Compliance with this standard will be enforced and monitored by the Facility Director through monthly fire drill log review and staff training. |
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 six out of six applicable records reviewed.
Client #1 was admitted on October 22, 2024 and was still active at the time of the inspection. The treatment plan was dated October 22, 2024.
Client #2 was admitted on December 17, 2024 and was still active at the time of the inspection. The treatment plan was dated December 17, 2024.
Client #3 was admitted on October 9, 2024 and was still active at the time of the inspection. The treatment plan was dated October 16, 2025.
Client #4 was admitted on July 23, 2024 and was still active at the time of the inspection. The treatment plan was dated July 23, 2024.
Client #6 was admitted on October 8, 2024 and was discharged on January 22, 2025. The treatment plan was dated October 8, 2024.
Client #7 was admitted on November 11, 2024 and was discharged on January 30, 2025. The treatment plan was dated November 11, 2025.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 13, 2024 licensing inspection.
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Plan of Correction
709.92a3 The Facility Directors will meet with the Clinical Director regarding needed changes to the Treatment Plan document in Carelogic. The Clinical Director will revise the Treatment Plan document in the agency's ECR to include the proposed type of support service. This will be in compliance by 6/16/25. Compliance with this standard will be monitored and enforced by the Facility Directors and Clinical Coordinators through staff training, quality reviews and supervision. |
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 outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of six applicable records reviewed.
Client #1 was admitted on October 22, 2024 and was still active at the time of the inspection. A treatment plan update was completed on December 9, 2024 and an update was due no later than February 9, 2025; however, it was not completed until February 11, 2025.
Client #3 was admitted on October 9, 2024 and was still active at the time of the inspection. A treatment plan update was completed on February 4, 2025 and an update was due no later than April 6, 2025; however, it was not completed until April 22, 2025.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 13, 2024 licensing inspection.
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Plan of Correction
709.92b The Facility Directors will meet with clinical staff to review 709.92b and to educate them that treatment plans shall be reviewed and updated at least every 60 days. The clinical staff will ensure treatment plans shall be reviewed and updated with the client at least every 60 days per policy. This will be in compliance effective 6/1/2025. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Directors through staff meetings, staff training, quality reviews, and supervision. |