INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25, 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 25, 2021, there were not 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 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.
This is a repeat citation from the April 10, 2020 inspection.
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Plan of Correction
Program manager will review findings with AOD clinical staff on 4/16/21 @ 10am.
Clinical staff will complete 25 hours of training per annual year, provide documentation of completion and Program manager will track on clinical staff training plans. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirement Facility Summary Report, the facility failed to comply with the client/counselor ratio of 35 to 1 active clients.
The client/counselor ratio for employee # 2 was 109/1.
14.50/37.50 = .386
42/.386= 108.8 = 109/1
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately Program manager will review open cases and close cases where clients are out of compliance.
Familylinks has hired two new therapists and open clients will be transferred appropriately to each new therapist.
Program manager will work with Director to reduce client caseloads and become in compliance with 35:1 ratio. Program manager will run weekly report to ensure therapists are in compliance. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the review of the fire drill logs, the facility failed to document a fire drill at least once a month.
The fire drill logs were reviewed for the period of May 2020 to February 2021. There was no fire drill documented for September 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program manager immediately reported to safety committee findings from licensing.
Program manager will work with safety committee to ensure fire drills are held monthly and documented each month for each facility location. Program manager requested that monthly documentation be emailed to her each month to keep track. |
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 five of seven client records.
Client # 3 was admitted on November 12, 2020. There was no client signature on the third -party payer release of information. Information was sent to the funder.
Client # 4 was admitted on October 8, 2020 and discharged on February 18, 2021. There was no client signature on the third -party payer release of information. Information was sent to the funder.
Client # 5 was admitted on October 19, 2020 and discharged on March 9, 2021. There was no client signature on the third -party payer release of information. Information was sent to the funder.
Client # 6 was admitted on October 9, 2020 and discharged on January 4, 2021. There was no client signature on the third -party payer release of information. Information was sent to the funder.
Client # 7 was admitted on October 14, 2020 and discharged on January 15, 2021. There was no client signature on the third -party payer release of information. Information was sent to the funder.
These findings were reviewed with facility staff during the licensing process.
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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 five of seven client records.
Client # 3 was admitted on November 12, 2020. There was no client signature on the third -party payer release of information.
Client # 4 was admitted on October 8, 2020 and discharged on February 18, 2021. There was no client signature on the third -party payer release of information.
Client # 5 was admitted on October 19, 2020 and discharged on March 9, 2021. There was no client signature on the third -party payer release of information.
Client # 6 was admitted on October 9, 2020 and discharged on January 4, 2021. There was no client signature on the third -party payer release of information.
Client # 7 was admitted on October 14, 2020 and discharged on January 15, 2021. There was no client 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. |
709.92(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 the review of client records, the facility failed to document the individual treatment and rehabilitation plan was developed with a client in three of six client records.
Client # 4 was admitted on October 8, 2020 and discharged on February 18, 2021. There was no documentation the treatment plan, developed on December 8, 2020, was developed with the client.
Client # 6 was admitted on October 9, 2020 and discharged on January 4, 2021. There was no documentation the treatment plan, developed on November 11, 2020, was developed with the client.
Client # 7 was admitted on October 14, 2020 and discharged on January 15, 2021. There was no documentation the treatment plan, developed on December 14, 2020, was developed with the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program manager will review documentation criteria with AOD clinical staff and train clinical staff on completing treatment plans with the client and documenting in the treatment plan and the clinical progress note.
Program manager will review every treatment plan and note prior to approving to ensure that treatment plans are reviewed/updated with client on a monthly basis. |
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 the review of client records, the facility failed to document the treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of four client records.
Client # 1 was admitted on October 6, 2020 and was still an active client at the time of the inspection. A treatment update was due to be completed by December 15, 2020. There was no documentation the treatment plan update had been completed.
Client # 3 was admitted on November 12, 2020 and was still an active client at the time of the inspection.. A treatment update was due to be completed by February 2, 2021. There was no documentation the treatment plan update had been completed.
Client # 4 was admitted on October 8, 2020 and discharged on February 18, 2021. A treatment update was due to be completed by February 2, 2021. There was no documentation the treatment plan update had been completed.
Client # 5 was admitted on October 19, 2020 and discharged March 9, 2021. A treatment update was due to be completed by January 11, 2021. There was no documentation the treatment plan update had been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately Program manager will review with counselors that treatment plans are to be reviewed and updated with clients every 60 days.
Program manager will ensure treatment plan reviews occur every 60 days. Program manager will run treatment plan report monthly to ensure that treatment plans are completed timely with clients. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to assure that services were provided according to the individual treatment and rehabilitation plan in five of six client records.
Client # 1 was admitted on October 6, 2020 and was still an active client at the time of the inspection. The treatment plan dated December 2, 2020 and an update on February 22, 2021 stated that the client was to receive one individual counseling session a week. Client did not receive weekly individual sessions in December 2020 and January and February 2021.
Client # 3 was admitted on November 12, 2020 and was still an active client at the time of the inspection. The treatment plan dated November 13, 2020 and an update on February 8, 2021 stated that the client was to receive one individual counseling session a week. Client did not receive weekly individual sessions in January and February 2021.
Client # 4 was admitted on October 8, 2020 and discharged on February 18, 2021. The treatment plan dated December 8, 2020 stated that the client was to receive one individual counseling session a week. Client did not receive weekly individual sessions in November and December 2020 and January 2021.
Client # 5 was admitted on October 19, 2020 and discharged on March 9, 2021. The treatment plan dated November 11, 2020 stated that the client was to receive one individual counseling session a week. Client did not receive weekly individual sessions in December 2020 and January and February 2021.
Client # 6 was admitted on October 9, 2020 and discharged on January 4, 2021. The treatment plan dated December 9, 2020 stated that the client was to receive one individual counseling session a week. Client did not receive weekly individual sessions in December 2020.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the September 10, 2020 inspection.
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Plan of Correction
Program Manager will meet with drug and alcohol therapists on 4/16/2021@ 10am to review results from licensing audit. Therapists will be provided with a copy of regulation 709.52 Treatment and rehabilitation services. Therapists and Program manager will review regulation regarding frequency of sessions outlined in treatment plans and ensure that frequency of sessions is being met and clear and appropriate documentation is enter into EHR system.
Effective immediately Program Manager will review each treatment plan/treatment plan update to ensure that frequency of treatment is being implemented as documented an accurately entered in the EHR.
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