INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 27, 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, Diakon Child, Family, and Community Ministries 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
|
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
During a physical plant inspection conducted on June 27, 2019, the facility failed to provide documentation of employee # 4 having fire extinguisher training completed upon employment.
Employee # 4 was hired as a counselor on January 4, 2018 and was still in that position at the time of the inspection. Documentation in the personnel record indicated fire extinguisher training was conducted on February 8, 2019.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff received training necessary to perform assigned tasks during emergencies on 7/15/19. Emergency Training will be completed by all new employees and reviewed by the Project Director within 7 days from hire. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
During a physical plant inspection conducted on June 27, 2019, the facility failed to provide documentation that employee # 4 received training on how to perform tasks during an emergency prior to working a shift. Also, the fire drill log did not indicate whether the fire alarm or smoke detector was operative the months of June through December 2018, January, March, May, and June 2019.
Employee # 4 was hired as a counselor on January 4, 2018 and was still in the position at the time of the inspection. Documentation in the personnel record indicated emergency training was conducted on February 8, 2019.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff received training necessary to perform assigned tasks during emergencies on 7/15/19. Emergency Training will be completed by all new employees and reviewed by the Project Director within 7 days from hire.
The Fire Drill Form was revised by the Program Director on 7/15/2019, to include the date, time, the amount of time it takes for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector is operative. All required items shall be documented on the approved form and reviewed by the project Director monthly following the unannounced fire drills.
|
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
During a licensing inspection conducted on June 27, 2019, the facility failed to provide documentation of the Policy and Procedure manual being updated annually by the Project director. The last documented update occurred on November 20, 2013.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Policy and Procedure manual was reviewed by the Project Director on 7/15/19. The policy manual will be reviewed on an annual basis by the Project Director. A signed statement indicating this review will be available for inspection. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
|
Observations
During a licensing inspection conducted on June 27, 2019, the facility failed to provide policies and procedures for reporting of unusual incidents that included the prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Unusual Incident Policy was updated on 7/15/19 by the Project Director and includes the ongoing monitoring of the corrective action plan. Staff will be updated on the policy changes by 8/07/19. All unusual incidents will be monitored by the Project Director. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
|
Observations
During a licensing inspection conducted on June 27, 2019, the facility failed to provide policies and procedures for reporting of unusual incidents that included the implementation of a timely and appropriate corrective action plan, when indicated
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Unusual Incident Policy was updated on 7/15/19 by the Project Director and includes the ongoing monitoring of the corrective action plan. Staff will be updated on the policy changes by 8/07/19. All unusual incidents will be monitored by the Project Director. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
|
Observations
During a licensing inspection conducted on June 27, 2019, the facility failed to provide policies and procedures for reporting of unusual incidents that included the ongoing monitoring of the corrective action plan.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Unusual Incident Policy was updated on 7/15/19 by the Project Director and includes the ongoing monitoring of the corrective action plan. Staff will be updated on the policy changes by 8/07/19. All unusual incidents will be monitored by the Project Director. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
|
Observations
During a licensing inspection conducted on June 27, 2019, the facility failed to provide policies and procedures for reporting of unusual incidents that included the reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Unusual Incident was updated on 7/15/19 by the Project Director and includes the reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. Staff will be updated on the policy changes by 8/07/19. All Unusual incidents will be monitored by the Project Director |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
During a licensing inspection conducted June 27, 2019, the facility failed to provide documentation of a preliminary treatment plan being completed in accordance with the facilities policy and procedures within 15 days of admission in two of seven client records reviewed.
Client # 2 was admitted on November 7, 2018 and was still active at the time of the inspection. The client ' s preliminary treatment plan was not completed until January 2, 2019.
Client # 5 was admitted on June 8, 2018 and was discharged on October 1, 2018. The client ' s preliminary treatment plan was not completed until July 9, 2018.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director provided staff training on 07/15/2019 on 709.91. Treatment and rehabilitation services. (b) Intake procedures shall include documentation of: (6) Psychosocial evaluation. . Project Counselors will complete Psychosocial Evaluations and Preliminary Treatment Plans in accordance with 709.91. Compliance will be monitored by the Project Director. |
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.
|
Observations
During a licensing inspection conducted on June 27, 2019, the facility failed to provide documentation of the treatment and rehabilitation plans being updated every 60 days in 3 of 7 records reviewed.
Client # 1 was admitted on October 11, 2018 and was still an active client at the time of the inspection. The last documented treatment plan update occurred on February 19, 2019. and the next update was due no later than April 19, 2019; however, there was no update documented in the record at the time of the inspection
Client # 4 was admitted on November 7, 2018 and was still an active client at the time of the inspection. The last documented treatment plan update occurred on March 26, 2019. and the next update was due no later than May 26, 2019; however, there was no update documented in the record at the time of the inspection.
Client # 7 was admitted on October 24, 2018 and was discharged on April 2, 2019. The initial treatment plan occurred on October 17, 2018. and the next update was due no later than December 17, 2018; however, the next update documented in the record at the time of the inspection was on January 2, 2019.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director provided staff training on 07/15/2019 on 709.92. Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. Project Counselors will complete Treatment Plan reviews and updates in accordance with 709.92. Compliance will be monitored by the Project Director.
|
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
During a licensing inspection conducted on June 27, 2019, the facility failed to provide documentation that the clients received counseling services according to their individual treatment and rehabilitation plan in 5 of 7 charts reviewed.
Client # 1 was admitted on October 11, 2019 and was still active at the time of the inspection. The treatment plan indicated one individual session conducted weekly. The chart's record of service and progress notes indicated the last session occurred on May 14, 2019.
Client # 2 was admitted on November 7, 2018 and was still active at the time of the inspection. The treatment plan indicated one individual session conducted weekly. The chart's record of service and progress notes indicated the last session occurred on May 7, 2019.
Client # 3 was admitted on October 11, 2019 and was still active at the time of the inspection. The treatment plan indicated one individual session conducted weekly. The chart's record of service and progress notes indicated the last session occurred on May 21, 2019.
Client # 4 was admitted on November 7, 2018 and was still active at the time of the inspection. The treatment plan indicated one individual session conducted weekly. The chart's record of service and progress notes indicated the last session occurred on May 21, 2019.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director provided staff training on 07/15/2019 on 709.92. Treatment and rehabilitation services. (c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan. Project Counselors will provide counseling services according to the individual treatment plan and compliance will be monitored by the Project Director. |