INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9, 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 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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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
During a licensing inspection conducted on July 9, 2019, the facility failed to provide documentation of the fire drill record indicating whether or not the fire alarm or smoke detector was operative.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Fire Drill Form was revised by the Program Director on 7/15/2019, to include the date, time, the amount of time it takes 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 is operative. All required items shall be documented on the approved form and reviewed by the project Director monthly following the unannounced fire drills. |
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 9, 2019, the facility failed to provide documentation of the Policy and Procedure manual being updated annually by the Project director. The last documented update occurred 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 9, 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 1, 3, 4, 5, and 7.
Client # 1 was admitted on January 23, 2019 and was still an active client at the time of the inspection. An informed and voluntary consent to disclose information was signed and dated on February 15, 2019 to a probation officer and January 23, 2019 to a probation Officer, DUI program, and insurance agency that allowed for the release of "services received, (individual/group), pass/fail urine screen, recommendations, and intake/discharge information".
Client # 3 was admitted on March 20, 2019 and was still an active client at the time of the inspection. An informed and voluntary consent to disclose information was signed and dated on March 20, 2019 to "CPDA" that allowed for the release of "treatment information".
Client # 4 was admitted on May 16, 2019 and was still an active client at the time of the inspection. A correspondence with a funding source was faxed on March 28, 2019 without a documented informed and voluntary consent to disclose information form.
Client # 5 was admitted on February 27, 2018 and discharged on September 26, 2018. A correspondence with a funding source was faxed on March 12, 2018 without a documented informed and voluntary consent to disclose information form.
Client # 7 was admitted on March 4, 2019 and discharged on April 22, 2019. An informed and voluntary consent to disclose information was signed and dated on March 4, 2019 to a probation officer and insurance agency that allowed for the release of "individual or group counseling, psych-evaluation, self-help assignments, follow through, and recommendations".
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director provided training on 7/15/2019 that outlined § 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.
Consents to release information will be monitored by Project Director and Compliance Department. |
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 9, 2019, the facility failed to provide policies and procedures for reporting of unusual incidents that included 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 9, 2019, the facility failed to provide policies and procedures for reporting of unusual incidents that included 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 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) (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 9, 2019, the facility failed to provide policies and procedures for reporting of unusual incidents that included the 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 9, 2019, the facility failed to provide policies and procedures for reporting of unusual incidents that included the 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 9, 2019, the facility failed to provide documentation assuring counseling services being provided according to the individual treatment and rehabilitation plan in three of seven records reviewed.
Client # 1 was admitted on January 23, 2019 and was still an active client at the time of the inspection. The comprehensive treatment plan, dated February 15, 2019 and last updated on June 3, 2019, indicated one individual and one group session weekly. The chart's record of service and progress notes indicated that the client did not receive individual sessions the weeks of:
February 3-9April 14-20June 9-15
February 24-March 2April 28-May 4June 23-29
March 17-23May 12-18
March 31-April 6May 26-June 1
And Group sessions the weeks of:
February 10-15, 17-22May 1-31
February 24-March 1June 1-22
March 10-16,17-23,24-30June 30-July 6
April 7-13,14-20,21-30
Client # 3 was admitted on March 20, 2019 and was still an active client at the time of the inspection. The comprehensive treatment plan, dated March 20, 2019 and last updated on June 10, 2019, indicated one individual session weekly. The chart's record of service and progress notes indicated that the client did not receive individual sessions the weeks of:
March 24-30June 9-15,16-22
April 7-13,14-20June 30-July 6
April 28-May 4
May 12-18
May 26-June 1
Client # 6 was admitted on August 1, 2018 and discharged on January 7, 2019. The comprehensive treatment plan, dated August 1, 2018 and last updated on October 16, 2018, indicated one individual session Bi-weekly. The chart's record of service and progress notes indicated that the client did not receive individual sessions:
September 2-22
October 7-13
October 21-November 10
The last documented session was on November 13, 2018
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will provided staff training on 07/15/19 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 9, 2019, the facility failed to provide documentation of a complete client record to include case consultations in four of seven records reviewed and follow-up information in two of seven records reviewed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director provided staff training on 07/15/19 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 |