INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 26, 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 & Children's Aid Society 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 on October 17, 2022 and still employed. Staff #4 was due to have the communicable disease trainings no later than October 17, 2023 but did not complete until May 6, 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. |
709.26 (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 annual written individual staff performance evaluations reviewed and signed by the employee in one of three applicable records.
Staff #4 was hired as a counselor on October 17, 2022 and still employed. Staff #4 most recent evaluation review period was October 2022 through October 2023. The annual performance evaluation was completed but not signed by the employee until September 23, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program director met with the CEO of the agency to review this deficiency on September 26 and the clinical supervisor on September 27. The CEO and program director identified two changes to ensure performance evaluations are completed and signed annually. The first change is to track annual review dates and complete them a week prior to the year date. The second is to make copies of all reviews to be kept with staff and at the Franklin office while the original is filed at the main office. Program director conveyed these changes to the clinical supervisor during their review and both agreed to implement this change as of September 30. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to include documentation of medical histories at intake in three of seven records reviewed.
Client #1 was admitted February 1, 2024 and discharged August 19, 2024.
Client #5 was admitted February 15, 2024 and still a current client.
Client #7 was admitted March 14, 2024 and still a current client.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 17, 2023 licensing inspection.
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Plan of Correction
Program Director and clinical supervisor reviewed the deficiencies regarding medical history documentation on September 30, 2024 with all clinical staff. Program Director and Clinical Supervisor developed a chart check list for intake and provided it to all clinical staff on October 7, 2024. Clinical Supervisor will review the checklist with clinical staff during weekly supervision to ensure all intake documentation is completed at intake.
Clinical staff will complete medical history for identified clients by October 31 and review with clinical supervisor during supervision.
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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 five of seven records reviewed.
Client #3 was admitted February 26, 2024 and discharged July 11, 2024. A treatment plan was completed on May 2, 2024 and an update was due by July 8, 2024 but not completed prior to discharge.
Client #4 was admitted February 8, 2024 and still a current client. A treatment plan was completed on March 6, 2024 and an update was due by May 5, 2024 but not completed until May 9, 2024. Another treatment plan was completed on July 9, 2024 and an update was due by September 7, 2024 but not completed at the time of the inspection.
Client #5 was admitted February 15, 2024 and still a current client. A treatment plan was completed on March 11, 2024 and an update was due by May 10, 2024 but not completed until May 16, 2024. Another treatment plan was due by July 15, 2024 but not completed until July 18, 2024. A third treatment plan update was due by September 16, 2024 but not completed until September 19, 2024.
Client #6 was admitted February 22, 2024 and still a current client. A treatment plan was completed on July 19, 2024 and an update was due by September 17, 2024 but not completed at the time of the inspection.
Client #7 was admitted March 14, 2024 and still a current client. A treatment plan was completed on June 14, 2024 and an update was due by August 13, 2024 but not completed until August 28, 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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