INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 4, 2025 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:
|
Plan of Correction
|
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on applicable staff records reviewed, the facility failed to provide documentation of an annual written individual staff performance evaluations reviewed and signed by the employee in one of three records.
Staff #3 was hired as a counselor on June 7, 2021 and still employed in that role at the time of the inspection. There was no documentation of an annual written individual staff performance evaluation since 2022.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff #3 will complete missing annual reviews for 2023 and 2024 by 4/1/25 to bring reviews current effective as of 4/1/25. Reviews will be added to employee record.
Employee reviews will be completed annually during the scheduled agency time frame in October. Program Management and Human Resources will ensure all staff have annual evaluations completed by the end of November of each year.
Person Responsible: Human Resources, Director of Behavioral Health
|
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services in two of six records.
Client #1 was admitted to outpatient on October 24, 2024 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on November 27, 2024, however, there was no documentation of type and frequency of services.
Client #2 was admitted to outpatient on May 21, 2024 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on July 26, 2024, however, there was no documentation of type and frequency of services.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Treatment plans will be corrected to add frequency and type of treatment during the next scheduled review. The electronic health record system was updated to include the option for frequency and type of treatment.
Treatment plans will be monitored for addition of type and frequency over the next 90 days. The electronic health record system settings will be reviewed quarterly with scheduled program updates.
Person Responsible: Therapist, Director of Behavioral Health
|