INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 8, 2025 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:
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Plan of Correction
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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.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in seven out of seven records reviewed.
Client #1 was admitted on February 4, 2025 and was still active at the time of the inspection. The treatment plan was dated February 4, 2025.
Client #2 was admitted on October 29, 2024 and was still active at the time of the inspection. The treatment plan was dated October 29, 2024.
Client #3 was admitted on November 13, 2024 and was still active at the time of the inspection. The treatment plan was dated November 13,2024.
Client #4 was admitted on December 11, 2024 and was still active at the time of the inspection. The treatment plan was dated December 11, 2024.
Client #5 was admitted on October 2, 2024 and was discharged on January 22, 2025. The treatment plan was dated October 2, 2024.
Client #6 was admitted on November 1, 2024 and was discharged on January 29, 2025. The treatment plan was dated November 1, 2024.
Client #7 was admitted on November 1, 2024 and was discharged on January 30, 2025. The treatment plan was dated November 1, 2024.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 10, 2024 licensing inspection.
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Plan of Correction
790.92a3 The Facility Directors will meet with the Clinical Director regarding needed changes to the Treatment Plan document in Carelogic. The Clinical 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 6/16/25. Compliance with this standard will be monitored and enforced by the Facility Directors and Clinical Coordinators through staff training, quality reviews and supervision. |
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
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven records reviewed.
Client #2 was admitted on October 29, 2024 and was still active at the time of the inspection. A treatment plan update was completed on December 17, 2024 and the next update was due no later than February 17, 2025; however, it was not completed until February 21, 2025.
Client #3 was admitted on November 13, 2024 and was still active at the time of the inspection. A treatment plan update was completed on December 30, 2024 and the next update was due no later than March 1, 2025; however, it was not completed until March 4, 2025.
Client #5 was admitted on October 2, 2024 and was discharged on January 22, 2025. A treatment plan update was completed on November 20, 2024 and the next update was due no later than January 20, 2025; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
790.92b The Facility Directors will meet with the clinical staff to review 790.92b and to educate them that Treatment Plans shall be reviewed and updated at least every 60 days. The clinical staff will ensure treatment plans shall be reviewed and updated with the client at least every 60 days per policy. This will be in compliance effective 6/1/2025. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinators through staff meetings, staff training, quality reviews and supervision. |
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 information within guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed 60 days following discharge.
Client #6 was admitted on November 1, 2024 and discharged on January 29, 2025. A follow up was due no later than March 30, 2025; however, it was not completed until April 17, 2025.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the June 10, 2024 licensing inspection.
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Plan of Correction
709.93a11 The Facility Directors will meet with the clinical staff to review 790.93a11 and to educate them that client Follow Up shall be completed and documented 60 days following client discharge per Diakon policy. The clinical staff will ensure Follow Up will be completed 60 days following a client's discharge. This will be in compliance effective 6/1/2025. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinators through staff meetings, staff training, quality reviews and supervision. |