INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 18-19, 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 Services of Warren County, Inc. 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to ensure staff were instructed in the use of fire extinguishers upon employment in one of five records.
Staff #1 was hired on April 1, 2024, as executive director and was still in the position at the time of inspection. The training was not completed as of the date of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Training was completed on 4/19/24 for Staff #1 after Exit Interview with DDAP auditor. All new staff will have a new hire checklist that will be completed by Supervisor and/or Office Manager to ensure fire safety training is completed day of hire. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one of five records.
Staff #1 was hired on April 1, 2024, as executive director and was still in the position at the time of inspection. The training was not completed as of the date of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Training was completed on 4/19/24 for Staff #1 after Exit Interview with DDAP auditor. All new staff will have a new hire checklist that will be completed by Supervisor and/or Office Manager to ensure emergency training is completed day of hire. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative information, the project director failed to prepare, annually update, and sign a written manual delineating project policies and procedures for the year 2023.
The last written sign off was documented on April 18, 2019.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Director will prepare, annually update and sign a written manual delineating project policies and procedures. Compliance Officer will confirm & review annually that the Executive Director has completed signature.
As recommended by DDAP Auditor was a complete review of policies by Executive Director and Director of Substance Abuse. This will be completed by 7/30/2024 to allow Executive Director and Director of Substance Abuse time to review policies thoroughly and get Board of Directors Approval for any updated policy and procedures before signing off on written policy and procedures manual. |
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.
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Observations
Based on a review of client records, the facility failed to document the disclosure of the criteria for discharge to clients, during the intake process, in four of seven records.
Client #2 was admitted on September 25, 2023, and was still an active client at the time of inspection.
Client #3 was admitted on September 5, 2023, and was still an active client at the time of inspection.
Client #4 was admitted on November 13, 2023, and discharged on February 20, 2024.
Client #6 was admitted on December 14, 2023, and discharged on April 11, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director and Director of Substance Abuse will develop a Client Handbook by 6/30/24 to meet requirements of disclosure to client of criteria for admission, treatment, completion and discharge. This will be reviewed with all open clients and at intake for all new clients. Client will sign acknowledgement that they reviewed the handbook. Director of Substance Abuse will conduct random monthly record reviews. |
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.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project which included hours of operation in seven of seven records.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Director of Substance Abuse will develop a Client Handbook by 6/30/24 to meet requirements of disclosure of hours of operation. This will be reviewed with all open clients and at intake for all new clients. Client will sign acknowledgement that they reviewed the handbook. Director of Substance Abuse will conduct random monthly record reviews. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in one of one applicable discharged record.
The facility's policy and procedure manual states an outcome survey is sent within 30 days for successful discharges, and a phone call within 30 days for unsuccessful discharges.
Client #4 was admitted on November 13, 2023, and successfully discharged on February 20, 2024.
There was no follow-up information documented in client records #4 ' s record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Policy was corrected in our electronic files on 6/17/22 but was not printed to replace old policy in handbook that auditor reviewed. Director of Substance Abuse has printed and added updated policy to printed manual as of 4/30/24. The current policy states that a survey or phone call will be completed for successful or unsuccessful discharges within 30 days. Staff were provided training, policy to review and notified the printed manual was updated. Director of Substance Abuse will conduct random monthly record reviews of client records to ensure that follow-ups are being completed. |