INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 1, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Diakon Family Life Services 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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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
During a licensing inspection conducted on July 1, 2019, the facility failed to provide documentation of the Project Director annually updating and signing the Policies and Procedures Manuel. The last documented update was on November 20, 2013.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Policy and Procedure manual was reviewed by the Project Director on 7/15/19. The policy manual will be reviewed on an annual basis by the Project Director. A signed statement indicating this review will be available for inspection. |
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.
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Observations
During a licensing inspection conducted on July 1, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 2, 3, and 5.
Client # 2 was admitted on January 29, 2019 and discharged March 28, 2019. There was no informed and voluntary consent for the disclosure of information contained in the client record for the funding source.
Client # 3 was admitted on August 8, 2018 and discharged May 9, 2019. There was no informed and voluntary consent for the disclosure of information contained in the client record for the funding source.
Client # 5 was admitted on April 8, 2019 and was still an active client at the time of the inspection. There was no informed and voluntary consent for the disclosure of information contained in the client record for the funding source.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will provide training on 7/15/19 that will outline § 709.28. Confidentiality and 4 Pa. Code 255.5 (b) for release of information that includes obtaining informed and voluntary consents for the disclosure of information. Voluntary consents for disclosure of information shall be obtained by clients and documented in the client record prior to the disclosure of information and will be monitored by the Project Director. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
During a licensing inspection conducted on July 1, 2019, the facility failed to provide policies and procedures documenting the prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual Incident Policy was updated by 7/15/19 by the Project Director and includes prompt review and identification of the causes directly or indirectly responsible for the unusual incident. Staff will be trained on the updated policy changes by 8/07/19. All unusual incidents will be monitored by the Project Director. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
During a licensing inspection conducted on July 1, 2019, the facility failed to provide policies and procedures for reporting unusual incidents to document the implementation of a timely and appropriate corrective action plan, when indicated.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual Incident Policy was updated on 7/15/19 by the Project Director and includes the implementation of a timely and appropriate corrective action plan, when indicated. Staff will be updated on the policy changes by 8/07/19. All unusual incidents will be monitored by the Project Director. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
During a licensing inspection conducted on July 1, 2019, the facility failed to provide policies and procedures for reporting unusual incidents that documented ongoing monitoring of the corrective action plan.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual Incident Policy was updated on 7/15/19 by the Project Director and includes the ongoing monitoring of the corrective action plan. Staff will be updated on the policy changes by 8/07/19. All unusual incidents will be monitored by the Project Director. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
During a licensing inspection conducted on July 1, 2019, the facility failed to provide policies and procedures for reporting unusual incidents that documented a reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual Incident was updated on 7/15/19 by the Project Director and includes the reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. Staff will be updated on the policy changes by 8/07/19. All Unusual incidents will be monitored by the Project Director |
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.
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Observations
During a licensing inspection conducted on July 1, 2019, the facility failed to provide documentation of the facility providing counseling services in accordance to the individualized treatment and rehabilitation plan in 6 of 7 records reviewed.
Client # 1 was admitted on February 4, 2019 and was discharged on May 28, 2019. A treatment plan developed with the client on February 18, 2019 indicated Individual sessions weekly. The chart's record of service and progress notes indicated that the client had only received sessions on March 4th, 2019 and April 8th, 2019.
Client # 3 was admitted on August 8, 2018 and was discharged on May 9, 2019. A treatment plan developed with the client on September 18, 2018 and updated November 14, and January 8, 2019 indicating Individual sessions weekly. The chart's record of service and progress notes indicated that the client had only received sessions on August 21, 2018, September 18, 2018, October 9 and 30, 2018, November 29, 2018 and January 8, 2019.
Client # 4 was admitted on March 20, 2019 and was still an active client at the time of the inspection. A treatment plan developed with the client on March 27, 2019 and updated May 15, 2019 indicating Individual sessions weekly. The chart's record of service and progress notes indicated that the client had only received sessions on May 22, 2019
Client # 5 was admitted on April 8, 2019 and was still an active client at the time of the inspection. A treatment plan developed with the client on May 15, 2019 indicated Individual sessions weekly and Family/Couple sessions weekly. The chart's record of service and progress notes indicated that the client had only received sessions on May 22, 2019.
Client # 6 was admitted on April 29, 2019 and was still an active client at the time of the inspection. A treatment plan developed with the client on May 8, 2019 indicated Individual sessions weekly. The chart's record of service and progress notes indicated that the client had only received sessions on May 13 and 21, 2019 and June 6, 2019.
Client # 7 was admitted on February 26, 2019 and was still an active client at the time of the inspection. A treatment plan developed with the client on March 6, 2019 and updated June 11, 2019 indicating Individual sessions weekly. The chart's record of service and progress notes indicated that the client had only received sessions June 11, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director provided staff training on 7/15/19 on 709.92. Treatment and rehabilitation services. (c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan. Project Counselors will provide counseling services according to the individual treatment plan and compliance will be monitored by the Project Director. |
709.93(a) 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:
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Observations
During a licensing inspection conducted on July 1, 2019, the facility failed to provide documentation of a complete client record to include a referral, case consultations, and follow-up information in client records # 1, 2, 3, 5, 6, and 7.
Client # 1 was admitted on February 4, 2019 and discharged on May 28, 2019. The client record did not contain documentation of case consultation notes, a referral and follow-up information.
Client # 2 was admitted on January 29, 2019 and discharged on May 28, 2019. The client record did not contain documentation of case consultation notes and follow-up information.
Client # 3 was admitted on August 8, 2018 and discharged on May 9, 2019. The client record did not contain documentation of a referral and follow-up information.
Client # 5 was admitted on April 8, 2019 and was still an active client at the time of the inspection. The client record did not contain documentation of case consultation notes.
Client # 6 was admitted on April 29, 2019 and was still an active client at the time of the inspection. The client record did not contain documentation of a referral.
Client # 7 was admitted on February 26, 2019 and was still an active client at the time of the inspection. The client record did not contain documentation of a referral.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director provided staff training on 7/15/19 on 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 will include documentation of case consultation notes, referral and follow-up information. Counseling staff will ensure that records are complete, including information relative to the client's involvement with the project. Compliance will be monitored by the Project Director |