INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 30, 2023 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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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document that each staff receive an annual written individual performance evaluation.
Employee #2, who was hired as a Facility Director on September 1, 2016, did not have an annual evaluation completed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.26 b3 The Project and Facility Director will assure each staff receive an annual written individual performance evaluation. At the time of inspection, the Facility Director was on FMLA and could not locate her most current signed performance eval. Upon her return on 7/10/23, it was located. This will be in compliance effective 7/12/2023. Compliance with this standard will be monitored and enforced by the Project Director, Facility Director and Clinical Coordinator through staff meetings 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 client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of five applicable records reviewed.
Client #2 was admitted on March 22, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 22, 2023 and an update was due no later than May 22, 2023; however, no update was completed.
Client #3 was admitted on September 20, 2022 and was still active at the time of the inspection. A treatment plan update was completed on December 5, 2022 and the update was due no later than February 5, 2023; however, the next update was completed on February 27, 2023.
Client #5 was admitted on February 22, 2023 and was discharged on May 17, 2023. A comprehensive treatment plan was completed on February 22, 2023 and an update was due no later than April 22, 2023; however, no update was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.92 b The clinical staff will assure treatment and rehabilitation plans shall be reviewed and updated at least every 60 days per Diakon Family Life Service's policy. If the client is not present for the review/development of a treatment plan review the clinical staff will develop the treatment plan update and review with client at next attended session. This will be in compliance effective 7/28/2023. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality reviews and supervision. |