INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 11, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the facilities policy and procedure manual and interviews with the facility staff, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.
This finding was reviewed with facility staff during the licensing process
|
Plan of Correction
The Policy & Procedure manual will
be reviewed on an annual basis by
the Project Director. A signed
statement indicating this review will
be available for inspection.
Compliance with this standard will
be monitored and enforced by the
Facility Director through staff
meetings and supervision. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on a review of facility policies, the facility failed to include all of the required client rights, including the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
The facility's client rights policy " 709.91 (A1) III. (a.) did not include age, creed, sex, color, handicap, or religion.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director will develop
written policies and procedures on
client rights which will emphasize the
project will not discriminate in the
provision of services on the basis of
age, race, creed, sex, ethnicity, color,
national origin, marital status, sexual
orientation, handicap or religion.
This policy will be revised and in
compliance by 7/1/24. These rights
are reviewed with the client during
the Intake session. The client signs
the Acknowledgement Form
showing they have been notified of
these rights. |
709.92(a)(3) 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:
(3) Proposed type of support service.
|
Observations
Based on a review of residential client records, the facility failed to document proposed type of support service on individual treatment plans in seven out of seven applicable records reviewed.
Client #1 was admitted on December 20, 2023, and was still active at the time of the inspection. The comprehensive treatment plan, completed January 11, 2024, did not document client support services.
Client #2 was admitted on December 18, 2023, and was still active at the time of the inspection. The comprehensive treatment plan, completed January 29, 2024, did not document client support services.
Client #3 was admitted on January 23, 2024, and was still active at the time of the inspection. The comprehensive treatment plan, completed February 6, 2024, did not document client support services.
Client #4 was admitted on February 1, 2024, and was discharged on May 14, 2024. The comprehensive treatment plan, completed February 16, 2024, did not document client support services.
Client #5 was admitted on June 29, 2023, and was discharged on May 29, 2024. The comprehensive treatment plan, completed July 24, 2023, did not document client support services.
Client #6 was admitted on December 21, 2023, and was discharged on April 8, 2024. The comprehensive treatment plan, completed January 10, 2024, did not document client support services.
Client #7 was admitted on September 25, 2023, and was discharged on May 1, 2024. The comprehensive treatment plan, competed October 12, 2023, did not document client support services.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Facility Director will revise the
Treatment Plan document in the
agency's ECR to include the
proposed type of support service.
This will be in compliance by 7/1/24.
Compliance with this standard will
be monitored and enforced by the
Facility Director and Clinical
Coordinators through staff training,
quality reviews 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 a review of outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in two out of six applicable records reviewed.
Client #1 was admitted on December 20, 2023, and was still active at the time of the inspection. The comprehensive treatment plan dated January 11, 2024, indicated 1-2 individual sessions per week. During the period between March 11, 2024, and April 11, 2024, only one individual session was documented in the client record.
Client #2 was admitted on December 18, 2023 and was still active at the time of the inspection. The comprehensive treatment plan dated January 29, 2024, indicated 1-2 individual sessions per week. During the period between March 1, 2024, and March 30, 2024, only two individual session was documented in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
709.92 (c) Facility will ensure that
treatment services offered are in
accordance with recommended
session frequency according to the
comprehensive treatment plan.
Clinical staff will be re-educated on
expectations regarding treatment
planning at next staff meeting on
7/11/24. The facility director will
monitor compliance on a monthly
basis.
|
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in three out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed every 90 days following admission.
Client #1 was admitted on December 20, 2023, and was still active at the time of the inspection. A case consultation was completed January 1, 2024, with the next consultation being due no later than April 1, 2024; however, the next documented case consultation was May 20, 2024.
Client #2 was admitted on admitted on December 18, 2023, and was still active at the time of the inspection. A case consultation was completed on January 29, 2024, with the next consultation being due no later than April 29, 2024; however, there were no additional case consultations documented in the client record.
Client #5 was admitted on June 29, 2023, and was discharged on May 29, 2024. A case consultation was due by September 29, 2023; however, it was not completed until October 11, 2023.
This is a repeat citation from the June 30, 2023 licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
709.93 (a) Facility will comply with
requirements to provide complete
records including case consultations
in accordance with facility's policy
and procedures. The facility director
will review compliance of policy on a
monthly basis.
|