INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 22, 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, Renew Family Services, LLC 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)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to ensure that employee #3, a counselor hired on April 1, 2018, received a minimum of 6 hours of HIV/AIDS training within the regulatory timeframe, based on a review of the facility's Staffing Requirement Facility Report and the employee's personnel file.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The staff has completed 6 hours of HIV/AIDS training as of 4/29/19. The employees are notified they have one year to complete the mandated trainings. At a six months the clinical director will remind them that they must be signed up for the training. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
The facility failed to create and implement written personnel policies and procedures, which is to include a compliance with state and federal employment laws and references to the project ' s utilization of volunteers, rules of conduct, supervision of staff, and the orientation of all new employees.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director is updating the policy manual within the next month to include specific facility procedures in regards to whether the site will use volunteers and if so in what matter, rules of conducts for all staff members, supervision of staff, and the orientation for all new employees to Renew Family Services, LLC.
All staff will be introduced to the updated manual during our treatment team meeting so any questions may be answered and addressed. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
The facility failed to include the purpose of the disclosure of information on a consent to release information form in one of six client records.
Client #6 was admitted on October 4, 2018 and was discharged on November 15, 2018. There was a consent form to an outside agency signed and dated by the client on October 22, 2018; however, the consent form was missing the purpose of disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director will review with staff during the next treatment team meeting that all consents must be filled out completely. All consents must explain the purpose for the disclosure in order for the consent to be valid.
If client #6 returns to RFS all consents will have the disclosure completed stating what can be released and why RFS can contact them on behalf of the client.
The facility has the most frequently used consents ( such as sober living houses, labs, etc) completely filled out saved in Zencharts as a template in order to assure that this deficiency will not occur again. All staff will be trained on how to complete consents. This will be reviewed every three months to ensure staff understands the importance to include the purpose of the disclosure. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client in one of one applicable record reviewed.
Client #6 was admitted on October 4, 2018 and was administratively discharged on November 15, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will notify all clients that are involuntary discharged by letter that they are terminated from Renew Family Services with an alternative program to go to.
The staff will be notified at the next treatment team meeting April 30, 2019. Client #6 will be sent a letter immediately (4/30/19) and her chart will reflect so.
The clinical director will conduct chart checks for the first month to two months when a new employee begins working at RFS. Thereafter the clinical director will check charts randomly every other month for all clinical staff. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
The facility failed to ensure that clients were afforded the opportunity to request an involuntary termination reconsideration in one of one applicable record reviewed.
Client #6 was admitted on October 4, 2018 and was administratively discharged on November 15, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients that are discharged involuntary will receive a letter stating they are discharged and can appeal this decisions within the first 30 days by contacting the facility director. The letter will provide all the information in order for the client to contact and state their case.
Client #6 will have a chance to appeal 30 days after the discharge letter is sent out on April 30, 2019. This process will be reviewed on April 30, 2019 during treatment team meeting with all staff so any questions can be answered. The letter will be provided during the meeting.
Clinical Director will check charts randomly every other month so this does not occur. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
The facility failed to properly document that the individual's comprehensive treatment and rehabilitation plan was developed with the client in two of six client records reviewed. Additionally, the facility failed to properly document the frequency of treatment services the client was to receive on the client's individual treatment plan in two of six client records reviewed.
Client #1 was admitted on June 4, 2018 and was still active at the time of the inspection. The comprehensive treatment plan, dated August 31, 2018, failed to include the frequency of treatment and rehabilitation services.
Client #4 was admitted on September 17, 2018 and was discharged on April 1, 2018. The comprehensive treatment plan was documented on September 18, 2018 in the facility ' s electronic system; however, there was no client signature, no staff signature, nor written documentation that the plan was developed with the client's input.
Client #5 was admitted on August 22, 2018 and was discharged on February 9, 2019. The comprehensive treatment plan, dated August 22, 2018, failed to include the frequency of treatment and rehabilitation services.
Client #6 was admitted on October 4, 2018 and was discharged on November 15, 2018. The comprehensive treatment plan was documented on October 4, 2018 in the facility ' s electronic system; however, there was no client signature, no staff signature, nor written documentation that the plan was developed with the client's input.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be notified to use the frequency of the treatment in order to properly document the amount of times this goal will be addressed within the treatment plan's time span.
All treatment plans will be signed by the client and staff when the treatment plan is formulated.
Client #1 The frequency of treatment will be updated April 30, 2019.
Client #4 If the client readmits the client will sign a new treatment plan to demonstrate they were part of formulating this treatment plan with the therapist.
Client #5 The frequency of the treatment plan will be updated by April 30, 2019.
Client #6 If the client ever readmits the next treatment plan will demonstrate that it was formulated with the client and therapist by providing both staff signatures on the comprehensive treatment within 15 days of admit.
The Clinical Director will randomly check charts every other month in order to prevent this from occurring again.
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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
The facility failed to provide treatment plan updates within the regulatory timeframe in four of six client records reviewed.
Client #1 was admitted on June 4, 2018 and was active at the time of inspection. The comprehensive treatment plan was completed on August 31, 2018 and the first update was due no later than November 1, 2018. However, the update was not completed until November 16, 2018. Additionally, the next update was due no later than January 16, 2019; however, the update was completed on March 11, 2019.
Client #2 was admitted on November 6, 2018 and was still active at the time of the inspection. The comprehensive treatment plan was completed on November 9, 2018 and the first update was due no later than January 9, 2018. However, the update was not documented in the client ' s record at the time of the inspection.
Client #3 was admitted on January 8, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was completed on January 22, 2019 and the first update was due no later than March 22, 2019. However, the update was not documented in the client ' s record at the time of the inspection.
Client #5 was admitted on August 22, 2018 and was discharged on February 9, 2019. The comprehensive treatment plan was completed on August 22, 2018 and the first update was due no later than October 22, 2018. However, the update was not completed prior to discharge.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
April 30, 2019 all staff will be notify of new procedures. Treatment plan updates will occur within the first 30 days and 60 days thereafter. A new treatment plan will be produced in order to be clear and concrete producing client and staff signature.
Client #1 this client will have a new updated treatment plan with both client and staff signature and after 60 days another one will be produced.
Client #2 this client will have a new treatment plan that is updated. Every 60 days the treatment plan will be updated with signatures from both client and therapist.
Client #3 this client treatment plan was updated and client and therapist signed. This client will have an updated treatment plan every 60 days until they are no longer at RFS.
Client #5 If client readmits new treatment plan will be started.
All treatment plan updates will be completed in the first thirty days then sixty days thereafter in order to never have treatment plans overdue after discharge.
The Clinical Director will check charts randomly every other month in order to prevent these deficiencies from occurring again. |