INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 6-9, 2021 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:
|
Plan of Correction
|
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.
|
Observations
Based on five of six client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record prior to the release of information in client record # 2, 3, 4, 5, and 6.
Client # 2 was admitted on March 31, 2021 and was discharged on May 27, 2021. There was no documentation of an informed and voluntary consent from the client for the disclosure of information for the funding source prior to obtaining authorization.
Client # 3 was admitted on February 10, 2021 and was discharged on May 12, 2021. There was no documentation of an informed and voluntary consent from the client for the disclosure of information for the funding source prior to obtaining authorization.
Client # 4 was admitted on March 31, 2021 and was discharged on May 27, 2021. There was no documentation of an informed and voluntary consent from the client for the disclosure of information for the funding source prior to obtaining authorization.
Client # 5 was admitted on March 31, 2021 and was discharged on May 19, 2021. There was no documentation of an informed and voluntary consent from the client for the disclosure of information for the funding source prior to obtaining authorization.
Client # 6 was admitted on March 29, 2021 and was discharged on May 25, 2021. There was no documentation of an informed and voluntary consent from the client for the disclosure of information for the funding source prior to obtaining authorization.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff education was provided on 7/21/2021 regarding consent to release information.
Re-iteration of 42 CFR was presented. Staff were given two articles with exams on Confidentiality and 42 CFR.
Consents to release information have been incorporated as part of the assessment and intake process as to ensure compliance moving forward.
|
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on one of six client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include the dated signature of the client. Informed and voluntary consent forms from the client were completed on behalf of the client from staff and only indicated a verbal consent from the client in client records # 1.
Client # 1 was admitted on April 28, 2021 and was still active at the time of the inspection.
An informed and voluntary consent from the client for the disclosure of information to a funding source and probation officer had a dated signature of a witness however, it only contained a verbal telehealth consent by the client.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Whereby telehealth is done 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: (4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients). When verbal consent is given during a telehealth session the clinical staff person will follow up with a written consent prior to the release of confidential client information. This will be in compliance effective 8/2/2021. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality review and supervision. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
Based on five of six client records reviewed, the facility failed to provide a complete client record to include the acknowledgement by the client that they were notified of their rights in client records # 1, 2, 4, 5, and 6.
Client # 1 was admitted on April 28, 2021 and was still active at the time of the inspection. There was no acknowledgement documented in the client record of being notified of their rights.
Client # 2 was admitted on April 28, 2021 and was discharged on May 27, 2021. There was no acknowledgement documented in the client record of being notified of their rights.
Client # 3 was admitted on February 10, 2021 and was discharged on May 12, 2021. There was no acknowledgement documented in the client record of being notified of their rights.
Client # 4 was admitted on March 31, 2021 and was discharged on May 27, 2021. There was no acknowledgement documented in the client record of being notified of their rights.
Client # 5 was admitted on March 31, 2021 and was discharged on May 19, 2021. There was no acknowledgement documented in the client record of being notified of their rights.
Client # 6 was admitted on March 29, 2021 and was discharged on May 25, 2021. There was no acknowledgement documented in the client record of being notified of their rights.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Client rights are gone over in depth at the intake session. The Acknowledgment of this information is one form signed by the client and the therapist. Clients are each offered a copy of all of the information presented to them, as well.
On 7/21/2021, staff were educated about the important of client rights and voluntary consent to treatment.
Chart audits will be conducted at random on a routine basis to ensure compliance with signed acknowledgment forms. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
|
Observations
Based on five of six client records reviewed, the facility failed to provide a complete client record to include intake procedures that disclose to the client the criteria for admission, treatment, completion and discharge in client records # 1, 2, 4, 5, and 6.
Client # 1 was admitted on April 28, 2021 and was still active at the time of the inspection. There was no acknowledgement documented in the client record to include the criteria for admission, treatment, completion and discharge.
Client # 2 was admitted on March 31, 2021 and was discharged on May 27, 2021. There was no acknowledgement documented in the client record to include the criteria for admission, treatment, completion and discharge.
Client # 4 was admitted on March 31, 2021 and was discharged on May 27, 2021. There was no acknowledgement documented in the client record to include the criteria for admission, treatment, completion and discharge.
Client # 5 was admitted on March 31, 2021 and was discharged on May 19, 2021. There was no acknowledgement documented in the client record to include the criteria for admission, treatment, completion and discharge.
Client # 6 was admitted on March 29, 2021 and was discharged on May 25, 2021. There was no acknowledgement documented in the client record to include the criteria for admission, treatment, completion and discharge.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Criteria for admission, treatment, and completion/discharge are all gone over in depth at the intake session. The Acknowledgment of this information is one form signed by the client and the therapist. Clients are each offered a copy of all of the information presented to them, as well.
On 7/21/2021, staff were educated about the important of client rights and voluntary consent to treatment.
Chart audits will be conducted at random on a routine basis to ensure compliance with signed acknowledgment forms. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
|
Observations
Based on five of six client records reviewed, the facility failed to provide a complete client record to include client orientation to the project which shall include project policies in client records # 1, 2, 4, 5, and 6.
Client # 1 was admitted on April 28, 2021 and was still active at the time of the inspection. There was no acknowledgement documented in the client record of being oriented to the project policies.
Client # 2 was admitted on March 31, 2021 and was discharged on May 27, 2021. There was no acknowledgement documented in the client record of being oriented to the project policies.
Client # 4 was admitted on March 31, 2021 and was discharged on May 27, 2021. There was no acknowledgement documented in the client record of being oriented to the project policies.
Client # 5 was admitted on March 31, 2021 and was discharged on May 19, 2021. There was no acknowledgement documented in the client record of being oriented to the project policies.
Client # 6 was admitted on March 29, 2021 and was discharged on May 25, 2021. There was no acknowledgement documented in the client record of being oriented to the project policies.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Orientation to the project and policies is gone over in depth at the intake session. The Acknowledgment of this information is one form signed by the client and the therapist. Clients are each offered a copy of all of the information presented to them, as well.
On 7/21/2021, staff were educated about the important of client rights and voluntary consent to treatment.
Chart audits will be conducted at random on a routine basis to ensure compliance with signed acknowledgment forms. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
|
Observations
Based on five of six client records reviewed, the facility failed to provide a complete client record to include client orientation to the project which shall include the hours of operation in client records # 1, 2, 4, 5, and 6.
Client # 1 was admitted on April 28, 2021 and was still active at the time of the inspection. There was no acknowledgement documented in the client record of being oriented to the hours of operation.
Client # 2 was admitted on March 31, 2021 and was discharged on May 27, 2021. There was no acknowledgement documented in the client record of being oriented to the hours of operation.
Client # 4 was admitted on March 31, 2021 and was discharged on May 27, 2021. There was no acknowledgement documented in the client record of being oriented to the hours of operation.
Client # 5 was admitted on March 31, 2021 and was discharged on May 19, 2021. There was no acknowledgement documented in the client record of being oriented to the hours of operation.
Client # 6 was admitted on March 29, 2021 and was discharged on May 25, 2021. There was no acknowledgement documented in the client record of being oriented to the hours of operation.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Hours of operation and crisis information is gone over in depth at the intake session. The Acknowledgment of this information is one form signed by the client and the therapist. Clients are each offered a copy of all of the information presented to them, as well.
On 7/21/2021, staff were educated about the important of client rights and voluntary consent to treatment.
Chart audits will be conducted at random on a routine basis to ensure compliance with signed acknowledgment forms. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
|
Observations
Based on five of six client records reviewed, the facility failed to provide a complete client record to include client orientation to the project which shall include the fee schedule in client records # 1, 2, 4, 5, and 6.
Client # 1 was admitted on April 28, 2021 and was still active at the time of the inspection. There was no acknowledgement documented in the client record of being oriented to the fee schedule.
Client # 2 was admitted on March 31, 2021 and was discharged on May 27, 2021. There was no acknowledgement documented in the client record of being oriented to the fee schedule.
Client # 4 was admitted on March 31, 2021 and was discharged on May 27, 2021. There was no acknowledgement documented in the client record of being oriented to the fee schedule.
Client # 5 was admitted on March 31, 2021 and was discharged on May 19, 2021. There was no acknowledgement documented in the client record of being oriented to the fee schedule.
Client # 6 was admitted on March 29, 2021 and was discharged on May 25, 2021. There was no acknowledgement documented in the client record of being oriented to the fee schedule.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All applicable fees are gone over in depth at the intake session. The Acknowledgment of this information is one form signed by the client and the therapist. Clients are each offered a copy of all of the information presented to them, as well.
On 7/21/2021, staff were educated about the important of client rights and voluntary consent to treatment.
Chart audits will be conducted at random on a routine basis to ensure compliance with signed acknowledgment forms. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
|
Observations
Based on five of six client records reviewed, the facility failed to provide a complete client record to include client orientation to the project which shall include the services provided in client records # 1, 2, 4, 5, and 6.
Client # 1 was admitted on April 28, 2021 and was still active at the time of the inspection. There was no acknowledgement documented in the client record of being oriented to the services provided.
Client # 2 was admitted on March 31, 2021 and was discharged on May 27, 2021. There was no acknowledgement documented in the client record of being oriented to the services provided.
Client # 4 was admitted on March 31, 2021 and was discharged on May 27, 2021. There was no acknowledgement documented in the client record of being oriented to the services provided.
Client # 5 was admitted on March 31, 2021 and was discharged on May 19, 2021. There was no acknowledgement documented in the client record of being oriented to the services provided.
Client # 6 was admitted on March 29, 2021 and was discharged on May 25, 2021. There was no acknowledgement documented in the client record of being oriented to the services provided.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Services provided by the project are gone over in depth at the intake session. The Acknowledgment of this information is one form signed by the client and the therapist. Clients are each offered a copy of all of the information presented to them, as well.
On 7/21/2021, staff were educated about the important of client rights and voluntary consent to treatment.
Chart audits will be conducted at random on a routine basis to ensure compliance with signed acknowledgment forms. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
|
Observations
Based on five of six client records reviewed, the facility failed to provide a complete client record to include client orientation to the project which shall include the consent to treatment in client records # 1, 2, 4, 5, and 6.
Client # 1 was admitted on April 28, 2021 and was still active at the time of the inspection. There was no acknowledgement documented in the client record of a consent to treatment.
Client # 2 was admitted on March 31, 2021 and was discharged on May 27, 2021. There was no acknowledgement documented in the client record of a consent to treatment.
Client # 4 was admitted on March 31, 2021 and was discharged on May 27, 2021. There was no acknowledgement documented in the client record of a consent to treatment.
Client # 5 was admitted on March 31, 2021 and was discharged on May 19, 2021. There was no acknowledgement documented in the client record of a consent to treatment.
Client # 6 was admitted on March 29, 2021 and was discharged on May 25, 2021. There was no acknowledgement documented in the client record of a consent to treatment.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Consent to treatment is gone over in depth at the intake session. The Acknowledgment of this information is one form signed by the client and the therapist. Clients are each offered a copy of all of the information presented to them, as well.
On 7/21/2021, staff were educated about the important of client rights and voluntary consent to treatment.
Chart audits will be conducted at random on a routine basis to ensure compliance with signed acknowledgment forms. |
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:
|
Observations
Based on five of six client records reviewed, the facility failed to provide a documentation of an individual treatment and rehabilitation plan being developed with the client in client records # 2, 4, 5, and 6.
Client # 2 was admitted on March 31, 2021 and was discharged on May 27, 2021. A comprehensive treatment and rehabilitation plan dated March 31, 2021 did not provide documentation that it was developed with the client.
Client # 4 was admitted on March 31, 2021 and was discharged on May 27, 2021. A comprehensive treatment and rehabilitation plan dated March 31, 2021 did not provide documentation that it was developed with the client.
Client # 5 was admitted on March 31, 2021 and was discharged on May 19, 2021. A comprehensive treatment and rehabilitation plan dated March 31, 2021 did not provide documentation that it was developed with the client.
Client # 6 was admitted on March 29, 2021 and was discharged on May 25, 2021. A comprehensive treatment and rehabilitation plan dated March 29, 2021 did not provide documentation that it was developed with the client.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The clinical staff shall assure that counseling services are provided according to the individual treatment and rehabilitation plan. The clinical staff will follow treatment plan recommendations regarding frequency of treatment. This will be in compliance effective immediately. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality review and supervision. |
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 four of six client records reviewed, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in client records # 1, 3, 4, and 5.
Client # 1 was admitted on April 28, 2021 and was still active at the time of the inspection. A treatment and rehabilitation developed on April 28, 2021 and updated on June 23, 2021 indicate one individual session a week. A review of progress notes and record of service document only one individual session between the weeks of May 28-June 28 and only three individual sessions between the weeks of April 28-May 28, 2021.
Client # 3 was admitted on February 10, 2021 and was discharged on May 27, 2021. A treatment and rehabilitation developed on February 10, 2021 and updated on April 9, 2021 indicate one individual session a week. A review of progress notes and record of service document only two individual sessions between the weeks of February 10-March 10, one individual session between the weeks of March 10-April 10, and two individual sessions between the weeks of April 10-May 10, 2021.
Client # 4 was admitted on March 31, 2021 and was discharged on May 27, 2021. A treatment and rehabilitation developed on March 31, 2021 indicate one to ten individual sessions a day. A review of progress notes and record of service document only three individual sessions between the weeks of March 31-April 30 and one individual session between the weeks of April 30-May 27, 2021.
Client # 5 was admitted on March 31, 2021 and was discharged on May 19, 2021. A treatment and rehabilitation developed on March 31, 2021 indicate one individual sessions a week. A review of progress notes and record of service document only three individual sessions between the weeks of March 31-April 30 and two individual sessions between the weeks of April 30-May 19, 2021.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 27, 2019 annual licensing inspection.
|
Plan of Correction
The clinical staff shall assure that counseling services are provided according to the individual treatment and rehabilitation plan. The clinical staff will follow treatment plan recommendations regarding frequency of treatment. This will be in compliance effective immediately. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality review and supervision. |