INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 6, 2024 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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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on applicable client records reviewed, the facility failed to provide a preliminary treatment plan in accordance with the facility policy and procedure manual in six of seven applicable records. The facility policy and procedure manual indicated a preliminary treatment plan be completed during the intake process.
Client #1 was admitted to outpatient on September 12, 2023 and still active at the time of the inspection. The preliminary treatment plan was to be completed on September 12, 2023, but was not completed at the time of the inspection.
Client #2 was admitted to outpatient on December 7, 2023 and still active at the time of the inspection. The preliminary treatment plan was to be completed on December 7, 2023, but was not completed at the time of the inspection.
Client #3 was admitted to outpatient on January 25, 2024 and still active at the time of the inspection. The preliminary treatment plan was to be completed on January 25, 2024, but was not completed at the time of the inspection.
Client #4 was admitted to outpatient on October 10, 2023 and discharged on February 16, 2024. The preliminary treatment plan was to be completed on October 10, 2023, but was not completed prior to discharge.
Client #5 was admitted to outpatient on October 30, 2023 and discharged on December 5, 2023. The preliminary treatment plan was to be completed on October 30, 2023, but was not completed prior to discharge.
Client #7 was admitted to outpatient on October 23, 2023 and discharged on January 3, 2024. The preliminary treatment plan was to be completed on October 23, 2023, but was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has reviewed preliminary treatment plans with intake and clinical staff for completion upon client entry into the program.
Program Manager will review charts monthly for the next four months or until consistently completed per agency's policy and DDAP regulation.
Responsible Person: Program Manager
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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 applicable client records reviewed, the facility failed to provide an initial comprehensive treatment and rehabilitation plan in accordance with the facility policy and procedure manual in five of six records reviewed.
The project policy and procedure manual indicated an initial comprehensive treatment and rehabilitation plan be completed within fifteen days of admission into the program.
Client #1 was admitted to outpatient on September 12, 2023 and still active at the time of the inspection. An initial comprehensive treatment plan was due no later than September 27, 2023, however this was not completed until October 9, 2023.
Client #2 was admitted to outpatient on December 7, 2023 and still active at the time of the inspection. An initial comprehensive treatment plan was due no later than December 22, 2023, however this was not completed until February 6, 2024.
Client #3 was admitted to outpatient on January 25, 2024 and still active at the time of the inspection. An initial comprehensive treatment plan was due no later than February 9, 2024, however this was not completed until February 14, 2024.
Client #6 was admitted to outpatient on July 25, 2023 and discharged on January 4, 2024. An initial comprehensive treatment plan was due no later than August 8, 2023, however this was not completed until August 17, 2023.
Client #7 was admitted to outpatient on October 23, 2023 and discharged on January 3, 2024. An initial comprehensive treatment plan was due no later than November 7, 2023, however this was not completed until November 9, 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility has reviewed documentation timeline with clinical staff for initial treatment planning and treatment planning updates.
Program Manager will review charts monthly for the next six months or until consistently completed per agency policy and DDAP regulation.
Responsible Person: Program Manager
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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 client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in two of three applicable records.
Client #4 was admitted to outpatient on October 10, 2023 and discharged on February 16, 2024. A treatment and rehabilitation plan was developed on October 26, 2023. A treatment and rehabilitation plan update was due no later than December 26, 2023, however this was not completed prior to discharge.
Client #6 was admitted to outpatient on July 25, 2023 and discharged on January 4, 2024. A treatment and rehabilitation plan was developed on August 17, 2023. A treatment and rehabilitation plan update was due no later than October 17, 2023, however this was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has reviewed documentation timelines with clinical staff to ensure review occurs every sixty days.
Program Manager will review charts monthly to ensure treatment plans reviews are occurring and timely.
Person Responsible: Program Manager
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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 client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in three of three applicable records. The facility policy and procedure manual indicate a case consultation to occur every ninety days.
Client #1 was admitted to outpatient on September 12, 2023 and still active at the time of the inspection. case consultation was due to occur no later than December 12, 2023, however this was not completed at the time of the inspection.
Client #4 was admitted to outpatient on October 10, 2023 and discharged on February 16, 2024. A case consultation was due to occur no later than January 10, 2024, however this was not completed prior to discharge.
Client #6 was admitted to outpatient on July 25, 2023 and discharged on January 4, 2024. A case consultation was due to occur no later than October 25, 2023, however this was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 20, 2023 annual licensing inspection.
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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 timeline.
Responsible Person: Program Manager
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