INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20, 2023 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(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of the facility policy and procedure for staff development, including the submitted update, the facility failed to address the policy and procedure for the development of the overall training plan and evaluation of the previous year ' s training plan.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the annual inspection completed on April 27-28, 2022.
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Plan of Correction
The facility revised the policy and procedure for staff development to include the Program Manager and Associate Director of Behavioral health as being responsible for completing the annual evaluation by December 31st of each year.
The overall plan and implementation will be monitored by quarterly. Program Manager will provide a report in regular supervision monthly to ensure the plan is being completed and followed.
Person Responsible: Program Manager ,Associate Director of Behavioral Health
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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 applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in five of six records. The facility policy and procedure manual indicates case consultations are to be completed upon admission and every sixty days thereafter.
Client #2 was admitted to outpatient treatment on June 30, 2022 and discharged on October 5, 2022. A case consultation was due to occur no later than August 30, 2022, however a case consultation was not documented in the client record until September 28, 2022.
Client #4 was admitted to outpatient treatment on January 19, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than March 9, 2023. There was no case consultation documented in the client record.
Client #5 was admitted to outpatient treatment on July 28, 2021 and was still active at the time of the inspection. A case consultation was due to occur no later than December 22, 2022, however a case consultation was not documented in the client record until January 20, 2023.
Client #6 was admitted to outpatient treatment on February 2, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than December 27, 2022, however a case consultation was not documented in the client record until February 20, 2023.
Client #7 was admitted to outpatient treatment on May 31, 2022 and discharged on August 2, 2022. A case consultation was due to occur no later than July 31, 2022. There was no case consultation documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has reviewed case consultation time frames with staff to ensure information was provided to all staff.
Program Manager will review charts monthly to ensure documentation is completed per the agency's established time line.
Responsible Person: Program Manager
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