INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 19, 2023 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 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director and/or facility director met the qualifications for their position in one record reviewed.
Staff #2 was promoted to facility director on April 3, 2023, and did not have the required experience prior to the promotion.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director and Facility Director will review regulations and compare to Facility Director's previous experience and qualifications and receive clarification from DDAP staff regarding terminology.-started 12/1, completed 12/4
Project Director will submit additional information regarding Facility Director's experience which demonstrates compliance with regulatory requirements by 12/8/23.
In the event there is a change in the Facility Director the following will be implemented:
Document how the candidate meets the personnel requirements in the areas of supervision, program planning (utilizing definition provided by DDAP staff), and direct service. This will be completed by Project Director and Human Resources Director-this document will be created for the current Facility Director and submitted to DDAP by 12/12/23. It will be updated as needed if there is a change in the Facility Director position.
The document of qualifications will be kept in the personnel file for the Facility Director-completed by 12/12/23 and updated as needed if there is a change in the Facility Director position.
Project Director and Human Resources Director will review current Facility Director job description to ensure regulatory requirements are included. If not, the job description will be updated with the information by 12/15/23
Project Director will send copy of current Facility Director job description to DDAP by 12/15/23. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to ensure a mechanism was used to collect feedback on completed training during the 2022-2023 training year in two of four applicable records.
Staff #2 was hired on September 28, 2015 and still a current employee. No feedback forms were submitted for the 2022- 2023 trainings completed.
Staff #4 was hired on March 21, 2022 and still a current employee. No feedback forms were submitted for the 2022-2023 trainings completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Clinical Supervisor met on November 15 to discuss the deficiencies related to staff submitting evaluations for trainings. After reviewing the policy it was determined that does not need to be changes in the policy. Clinical Supervisor also reviewed the policy with the identified staff members number 2 and 4 at this location to ensure that they submit evaluations with all trainings completed. Clinical Supervisor and Program Director will also review the policy with all staff at the next staff meeting on December 15, 2023. All staff will be informed that evaluation forms will need to be completed for all trainings and submitted to the Program Director for their training files.
Program Director will maintain a spreadsheet of submitted trainings and evaluations attached to monitor that each staff submits the evaluation with the certificate of completion.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to complete a written training plan for each employee annually in one of five records reviewed.
Staff #1 has been employed since January 22, 2008 and still a current employee. Staff #1 had no individual training plan for the 2023-2024 training year at the time of onsite inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Executive Director met to discuss deficiencies related to this policy. Executive Director acknowledged not completing a training plan and it was determined that no change in policy needs to occur at this time. Executive Director has also indicated stepping down as the Project Manager and is currently taking the appropriate steps for this. The incoming Project Manager has reviewed the policies on training on November 9 and has an active training plan for the 23'-24' fiscal year.
Project Manager and Program Director will review training plans during annual evaluations to ensure training plans are maintained according to policy.
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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 of one applicable employees received the minimum of at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Staff #4 was hired as a counselor assistant on March 21, 2022 and still employed at time of inspection. Staff #4 was due to have the communicable disease trainings no later than March 21, 2023. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from November 30, 2022.
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Plan of Correction
Program Director met with the Clinical Supervisor on November 15 to discuss training needs for staff member #4. Clinical Supervisor identified difficulty of enrolling in an open training for staff member # 4. As a plan of correction the Program Director enrolled staff member #4 in a TB training sponsored by DDAP on December 7, which will be a virtual training. Staff member #4 will complete this training to satisfy requirements for communicable diseases.
Program director will monitor and ensure all staff are enrolled in required trainings as part of onboarding. Current staff will have trainings reviewed bi-annually by program director to ensure required trainings are being completed within the necessary time frame.
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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 a review of personnel records, the facility failed to ensure the project director and/or facility director completed at least 12 clock hours of training annually in one of two applicable records reviewed.
Staff #1 has been employed since January 22, 2008 and still a current employee. Staff #1 completed no training hours during the facilities 2022-2023 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director met with the Executive Director regarding the deficiency in training hours for the project director. The Executive Director identified stepping down as the Project Director and on November 9 reviewed the training expectations with the incoming Project Director. No changes in policies were deemed necessary as the incoming Project Director reviewed and confirmed expectations for training.
Incoming Project Director will adhere to all required training requirements and complete a minimum of 12 hours annually moving forward.
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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.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in one of one applicable records reviewed.
Staff #5 was hired on May 13, 2023 and still a current employee has not been trained on the use of fire extinguishers as of the date of onsite inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director met with the Human Resource Manager, Executive Director, and Clinical Supervisor to review policy deficiencies in this area. On November 9, 2023 the Human Resource Manager and Program Director collaborated to create a training curriculum on fire safety, fire extinguisher use, and emergency planning. This training will be reviewed with all staff members during January 2024 staff meeting and will be implemented as part of the onboarding training for all new staff. |
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.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one of one applicable records reviewed.
Staff #5 hired on May 13, 2023 and still a current employee has not been trained to perform assigned tasks during emergencies as of the date of onsite inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director met with the Human Resource Manager, Executive Director, and Clinical Supervisor to review policy deficiencies in this area. On November 9, 2023 the Human Resource Manager and Program Director collaborated to create a training curriculum on fire safety, fire extinguisher use, and emergency planning. This training will be reviewed with all staff members during January 2024 staff meeting and will be implemented as part of the onboarding training for all new staff. |
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 one of seven applicable records reviewed.
Client #2 was admitted on March 6, 2023 and discharged on August 16, 2023. On March 6, 2023 the client signed a release to their emergency contact as well as probation, both of which did not include purpose of disclosure on the release of information.
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 Release of Information documentation and identified the error. Clinical Supervisor will review with staff during staff meeting on December 15 the process of completing Releases, including the name, address, contact number, information to be released, start date, end date, expiration date, and purpose of release. Clinical Supervisor and Program Director both will be responsible for review and quality assurance as the reviewers of all releases completed by staff. |
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 seven of seven records reviewed.
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 policy related to medical history as well as the Electronic Health Record program utilized on November 22, 2023. It was identified that medical history can be completed through utilization of a 'Medical Profile' link in the individual's profile. Clinical Supervisor will review this process with all clinical staff and they will begin completing the medical history as part of the biopsychosocial process immediately. Clinical Supervisor and Program Director will be responsible for ensuring this is completed within the three session timeframe of the biopsychosocial.
For all clients active during the review time, staff will complete medical history at the next scheduled individual session with the client beginning on 11/22/23, the date they were notified of this protocol.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to complete initial treatment plans in a timely fashion according to agency policy and procedure manual in three out of seven records.
According to agency policy and procedures, the preliminary treatment plan is completed at intake, initial treatment plan is completed by 30 days, and all additional updates are done every 60 days thereafter.
Client #3 was admitted on April 19, 2023 and discharged on July 14, 2023. Client #3 preliminary treatment plan was completed on April 19, 2023 and initial treatment plan was due by May 19, 2023 but not completed until June 6, 2023.
Client #5 was admitted on March 15, 2023 and still a current client. Client #5 preliminary treatment plan was completed on March 15, 2023 and initial treatment plan was due by April 14, 2023 but not completed until July 3, 2023.
Client #6 was admitted on April 4, 2023 and still a current client. Client #6 preliminary treatment plan was completed on April 4, 2023 and initial treatment plan was due by May 4, 2023 but not completed until June 27, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On November 15, 2023 Clinical Supervisor and Program Director discussed deficiencies related to treatment plans of identified clients number 3, 5, and 6. There were no policy issues related to this so citation so no changes will be made related to policy. Clinical Supervisor reviewed policy will all clinical staff during individual supervisions. Quality assurance procedures have been established within the electronic charting program to notify staff one week prior to all treatment plan services being due. Clinical Supervisor and Program Director will assure quality and adherence to policy through electronic monitoring and weekly supervision with individual counselors. |
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 two out of six records reviewed.
Client #2 was admitted on March 6, 2023 and discharged on August 16, 2023. A treatment plan was completed on April 5, 2023 and an update was due by June 5, 2023 but not completed until June 28, 2023.
Client #7 was admitted on June 26, 2023 and still a current client. A treatment plan was completed on July 19, 2023 and an update was due by September 18, 2023 but not completed until October 11, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During review on November 15, 2023 Program Director and Clinical Supervisor identified deficiencies related to treatment plan updates being completed on time. It was identified that implementing the electronic reminder one week prior to the treatment plan being due will adequately address these deficiencies. Clinical Supervisor has also discussed this policy with all staff during supervision. Staff will be monitored by both Clinical Supervisor and Program Director to ensure compliance and quality control. |