INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 25, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Family Service and Children's Aid Society of Venango 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:
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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
Based on a review of personnel records, the facility failed to ensure that one employee received the minimum of at least 4 hours of TB/STD and other health related topics within the first year of employment in one of one records.
Staff #4 was hired as a counselor assistant on June 27, 2022 and promoted to counselor on July 1, 2023. Staff #4 was due to have the communicable disease trainings no later than June 27, 2023 but did not complete until April 2, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed this deficiency with the Human Resource Manager on September 30. Program Director included scheduling TB/STD training as part of orientation so that all new hires will schedule for this training within the first week of hire. This addition to orientation was implemented immediately with all new hires after September 30, 2024 to ensure this training is completed within the first year. |
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
Based on a review of client records, the facility failed to obtain an informed and voluntary consent which included purpose of disclosure in four of seven applicable records reviewed.
Client #1 was admitted February 6, 2024 and discharged July 3, 2024. All releases signed on February 6, 2024 did not include purpose of disclosure.
Client #2 was admitted March 6, 2024 and discharged August 14, 2024. All releases signed on March 6, 2024 did not include purpose of disclosure.
Client #5 was admitted February 22, 2024 and still a current client. All releases signed on February 22, 2024 did not include purpose of disclosure.
Client #6 was admitted March 13, 2024 and still a current client. All releases signed on March 13, 2024 did not include purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 18, 2023 licensing inspection.
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Plan of Correction
Program Director reviewed this deficiency with the Clinical Supervisor on September 27 and then with all clinical staff on September 30 during a staff meeting. Program Director reviewed requirements for releases of information, created a check list for all clinical staff to follow when filling out a release of information, and had all clinical staff sign an acknowledgement of understanding following thirty (30) minutes of training on this process.
Beginning September 30, 2024, clinical supervisor and program director will review all releases of information to ensure compliance. If any part of the required documentation is missing clinical staff will be redirected to complete a new release of information at the client's next individual session.
Clients #5 and #6 completed releases updating the purpose of disclosure on 10/1/24.
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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
Based on a review of client records, the facility failed to complete treatment plan updates at least every 60 days in four of seven records reviewed.
Client #3 was admitted March 7, 2024 and discharged August 14, 2024. A treatment plan was completed on April 5, 2024 and an update was due by June 4, 2024 but not completed until June 20, 2024.
Client #4 was admitted March 22, 2024 and discharged August 25, 2024. A treatment plan was completed on April 26, 2024 and an update was due by June 25, 2024 but not completed until July 3, 2024.
Client #5 was admitted February 22, 2024 and still a current client. A treatment plan was completed on March 18, 2024 and an update was due by May 17, 2024 but not completed until May 20, 2024.
Client #6 was admitted March 13, 2024 and still a current client. A treatment plan was completed on June 7, 2024 and an update was due by August 6, 2024 but not completed until August 9, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director discussed this deficiency with the Chief Executive Officer during licensing and then all clinical staff during the staff meeting on September 30, 2024. Program Director will meet with the EHR administrator to implement trigger notifications for treatment plans one (1) week prior to their due date. clinical staff will schedule to complete treatment plan updates fifty-three (53) days after previous treatment plan was completed. The EHR Administrator and Program Director will implement this trigger notification by November 30, 2024.
Program Director and Clinical Supervisor will also review all upcoming treatment plans with clinical staff during weekly supervisions. Clinical Supervisor will maintain an excel spreadsheet identifying the due dates of all treatment plans for staff to track.
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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 an attempted follow up with clients following discharge from the facility in one of two applicable records reviewed.
According to agency policy and procedure manual, follow up with discharged clients is as follows: successful discharges are followed up within one month, unsuccessful or any other type of discharge is followed up with in one week.
Client #3 was admitted March 7, 2024 and discharged August 14, 2024. No follow up attempts were documented for this client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program director and clinical supervisor reviewed the follow-up procedure for all client discharges. Program director reviewed this policy with all clinical staff on September 30, 2024 during the staff meeting. Administration identified that the policy was sufficiently functional for staff to follow up with clients. Program director and clinical supervisor met with both staff at facility license number 617019. During this meeting clinical staff were informed to maintain record of discharge and follow-up attempts. Clinical supervisor will follow up with each clinical staff weekly during supervision to verify that all discharges have been scheduled for follow-up contact according to the policy. |