INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 26, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Familylinks, Inc 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)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of administrative documentation, the facility failed to provide staff persons certified in CPR so that at least one person trained in this skill was onsite during the project's hours of operation. At the time of the inspection on March 26, 2021, there were no currently CPR certified staff. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Therapist will be trained in CPR/FA on 4/28/21.
Familylinks is training a staff member through the train the trainer program to become an internal CPR/FA instructor and CPR and FA will be scheduled with all staff during orientation to ensure coverage at the program.
Program manager will review training plans monthly with all therapists to ensure compliance.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on the review of personnel records, the facility failed to document that the project director completed at least 12 clock hours of annual training. Employee # 1 was hired as the project director on December 2, 2019. The employee required at least 12 hours of annual training for the 2020 training year. There was only 3 hours of training documented for 2020. These findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Program director has completed updated training plan and will register for required trainings and provide documentation of completion. Program manager will review training plan with director monthly and verify completion of trainings. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on the review of personnel records, the facility failed to document that the counselor completed at least 25 clock hours of annual training. Employee # 2 was hired as a counselor on April 30, 2018. The employee required at least 25 hours of annual training for the 2020 training year. There was only 3 hours of training documented.These findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Program Manager will review findings with AOD clinical staff on 4/16/2021 @ 10am.
Clinical staff will complete 25 hours of training per annual year, provided documentation of completion and Program manager will track on clinical staff's training plans and review monthly. |
709.28 (c) 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.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client in seven of seven client records. Client records # 1, 2, 3, 4, 5, 6 and 7 did not document a client's signature for the third -party payer release of information. Information was sent to the funder. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the September 10, 2020 annual licensing inspection.
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Plan of Correction
Releases were sent immediately via mail to all clients. Facility will ensure that releases are received prior to releasing information. Counselor will check chart prior to releasing any information. Program Manager will monitor compliance by reviewing charts monthly. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client that included the dated signature of the client, in seven of seven client records. In client records # 1, 2, 3, 4, 5, 6 and 7, there was no client's signature on the third -party payer release of information. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Releases were immediately mailed to clients. Facility will ensure that releases of information are received with client signature and date prior to releasing any information. Counselor will check chart prior to releasing any information. Program manager will monitor compliance by reviewing charts monthly. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychsocial evaluation in three of three client records. Client # 1 was admitted on December 10, 2020. There was no documentation of a psychosocial evaluation. Client # 2 was admitted on November 6, 2020. There was no documentation of a psychosocial evaluation. Client # 3 was admitted on November 20, 2020. There was no documentation of a psychosocial evaluation. These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Clinical staff were trained on new Co-occurring Disorder assessment that includes Biopsychosocial in assessment. Program manager will review each assessment as soon as completed and monitor for compliance on a weekly basis. |