INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 24, 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 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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704.11(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 2023-2024 training year in one of four applicable records.
Staff #4 was hired on April 15, 2019 and still a current employee. Staff #4 did not complete feedback forms on completed trainings for the 2023- 2024 training year except for the 6 hours of training which were completed on June 28, 2024.
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 reviewed the policy for submitting training certificates along with evaluations with all staff on September 30 during a staff meeting. Program Director and Clinical Supervisor spoke to staff #4 on September 30 individually to address deficiencies in their evaluations for trainings prior to June 28. Staff #4 was issued verbal coaching and instructed to complete evaluations for completed trainings before October 24, 2024.
Program Director will maintain the active training log and review it during supervision with the Clinical Supervisor weekly. The Clinical Supervisor will then review individual training logs with all staff during supervision to ensure evaluations are turned in at the next supervision following the training.
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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 #5 was hired as a counselor assistant on June 27, 2022 and promoted to counselor on July 1, 2023. Staff #5 was due to have the communicable disease trainings no later than June 27, 2023 but did not complete until April 2, 2024.
The 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 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. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days. The facility had an unusual incident occur June 5, 2024 which involved death of a client. The facility had not submitted a written unusual incident report to the Department at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director reviewed this deficiency with the Human Resource Manager and Chief Executive Officer of FSCAS. Clarity was provided to all staff that unusual incident reports involving death apply to active clients off campus and regardless of the nature of death. The Program Director submitted an unusual incident report on October 17 regarding this identified incident. Program Director will submit unusual incident reports for any active client death effective September 30,2024. |
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 four of seven records reviewed.
Client #1 was admitted February 6, 2024 and discharged August 19, 2024.
Client #3 was admitted March 4, 2024 and discharged September 9, 2024.
Client #4 was admitted April 2, 2024 and still a current client.
Client #5 was admitted March 26, 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(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 four 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 #1 was admitted February 6, 2024 and discharged August 19, 2024. Client #1 preliminary treatment plan was completed on February 6, 2024 and initial treatment plan was due by March 7, 2024 but not completed until March 21, 2024.
Client #2 was admitted March 4, 2024 and discharged June 7, 2024. Client #2 preliminary treatment plan was completed on March 4, 2024 and initial treatment plan was due by April 3, 2024 but not completed until April 17, 2024.
Client #4 was admitted April 2, 2024 and still a current client. Client #4 preliminary treatment plan was completed on April 2, 2024 and initial treatment plan was due by May 2, 2024 but not completed at the time of the inspection.
Client #7 was admitted May 14, 2024 and still a current client. Client #7 preliminary treatment plan was completed on May 14, 2024 and initial treatment plan was due by June 13, 2024 but not completed until June 21, 2024.
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 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. For all initial treatment plans clinical staff will schedule to complete them twenty-three (23) days after intake. 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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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 five applicable records reviewed.
Client #1 was admitted February 6, 2024 and discharged August 19, 2024. A treatment plan was completed on May 17, 2024 and an update was due by July 16, 2024 but not completed until July 22, 2024.
Client #3 was admitted March 4, 2024 and discharged September 9, 2024. A treatment plan was completed on March 4, 2024 and an update was due by May 3, 2024 but not completed until June 4, 2024. Additionally another treatment plan was due by August 3, 2024 but no further updates were completed.
Client #5 was admitted March 26, 2024 and still a current client. A treatment plan was completed on June 26, 2024 and an update was due by August 25, 2024 but no further updates were completed.
Client #6 was admitted May 13, 2024 and still a current client. A treatment plan was completed on June 10, 2024 and an update was due by August 9, 2024 but no further updates were completed.
Client #7 was admitted May 14, 2024 and still a current client. A treatment plan was completed on June 21, 2024 and an update was due by August 20, 2024 but no further updates were completed.
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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709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in four of seven applicable records.
The facility's policy and procedure manual states a case consultation must be completed 90 days following admission and then every 60 days thereafter.
Client #4 admitted April 2, 2024 and still a current client. A case consultation was due by July 1, 2024 but not completed until August 2, 2024.
There were no case consultations found in the following client records.
Client #5 was admitted March 26, 2024 and still a current client.
Client #6 was admitted May 13, 2024 and still a current client.
Client #7 was admitted May 14, 2024 and still a current client.
These findings were reviewed with the 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, Clinical Supervisor, and all clinical staff reviewed this deficiency during the staff meeting on September 30, 2024. Program Director reviewed policies of case consultations being completed for treatment plan updates, team meetings, change of level of care, and discharge. Program Director and Clinical Supervisor will implement clinical review of these events during weekly supervisor to ensure all clinical staff are completing case consultations when treatment plan updates are completed.
Clinical Supervisor and Program Director will review all other active clients and follow up with clinical staff on identified case consultations that need to be completed.
All case consults that were identified missing will be completed by October 31, 2024
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