INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 2, 2008 through December 4, 2008, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Service Association of Bucks County 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 and a plan of correction is due on Januaary 2, 2009.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records on December 2, 2008, the facility failed provide documentation that a clinical supervisor who has not functioned for 2 years as a supervisor in the provision of clinical services completed a core curriculum in clinical supervision.
Findings:
Employee #4 was hired as a clinical supervisor for the facility on 4/1/2008 and did not have 2 years prior supervisory experience in the provision of clinical services. The facility failed to document that employee #4 completed a core curriculum in clinical supervision.
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Plan of Correction
The Director of Clinical Services will contact BDAP by December 31, 2008 to request information as to the date and location of the next BDAP sponsored Core Curriculum in Clinical Supervision training. Employee #4 will attend the next scheduled training. In the interim Employee #4 will not supervise Drug and Alcohol cases. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to include within the informed and voluntary consent forms the right for the client to verbally revoke the consent.
Findings:
Eight client records were reviewed on December 4, 2008. Informed and voluntary consent forms were required in six records. The "Authorization for Use/Disclosure of Information" documented the client could only revoke the consent in writing in six of six client records, #1, 2, 3, 4, 5, and 6.
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Plan of Correction
The Director of Clinical Services and the Office Manager have begun the process of removing all "Authorization for Use/Disclosure of Information" forms which permit clients to revoke voluntary consent in writing only and replacing them with revised "Authorization for Use/Disclosure of Information" forms which allow for both verbal and written revocation of consent. |
709.32(c)(5) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(5) Security of drugs.
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Observations
Based on a review of administrative records, the facility failed to document a policy for medication control that includes the loss, theft, or misuse of drugs.
Findings:
Based on a review of the facility's policy and procedure manual on December 2, 2008, the facility failed to document a policy for medication control that includes the loss, theft, or misuse of drugs.
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Plan of Correction
The Director of Clinical Services, the Director or Nursing, and the Director of Quality Assurance and Compliance will meet and develop a policy statement, for inclusion in Policy CS.13, Medication Services, which will specifically address the loss, theft, or misuse of drugs. |
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 occurred as per facility policy. Facility Policy states follow-up will occur at 15- and 30-day intervals following a client's discharge.
Findings:
Eight client records were reviewed on December 4, 2008. Documentation of follow-up was required in four client records. The facility failed to document follow-up for two of four client records, #6 and 8.
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Plan of Correction
The assigned Clinical Supervisor will discuss records #6 and #8 with the assigned clinician; will review facility policy; and will stress the importance of 15- and 30-day post-discharge contact with clients. At a staff meeting scheduled for January 14, 2009, the Director of Clinical Services will review and stress the importance of adhering to facility policy which requires post-discharge follow-up contact with clients at 15- and 30-day intervals. Clinical supervisors will monitor client records to ensure ongoing compliance and proper documentation. |