INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1-3, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Diakon Child, Family and Community Ministries 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of employee # 14's personnel record, the facility failed to provide documentation of the core curriculum in clinical supervision training for clinical supervisors who have not functioned for two years as supervisors in the provision of clinical services.
Employee # 14 was promoted to a clinical supervisor position on August 16, 2021. There was no documentation of at least two years of supervision experience or the core curriculum training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Met with employee on 6/8/2022 to discuss the necessary aspects of supervision and training.
Employee will have core curriculum training immediately.
Employee will continue to have bi-weekly supervision in her current role.
Clinical Director will monitor for training and supervision compliance.
Employee will not provide direct supervision to staff until she has the clinical supervision training completed.
Moving forward, staff that are seeking promotion will need to have completed all necessary trainings before application can be submitted for transfer or promotion.
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on one of fourteen employee personnel records reviewed, the facility failed to provide documentation of the qualification of counselors for employee # 6.
Employee # 6 was hired as a counselor on December 20, 2021 and was still in this position at the time of the inspection. Based on a review of employee # 6's personal record and resume, there was no documentation of at least one year of clinical experience with a bachelor's degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Met with employee on 6/9/2022.
Employee will continue with weekly supervision until she meets the requirements of 704.7B.
Clinical director will monitor for supervision requirements and staffing needs.
Moving forward, clinical director will monitor necessary trainings on a quarterly basis and follow up with staff with outstanding trainings.
Also moving forward, facility will utilize the role of counselor assistant for staff members not meeting regulatory requirements for experience. |
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 and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee # 14 received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee #14 was hired as a counselor on August 6, 2018 and promoted to clinical supervisor on August 16, 2021 and was still in this position at the time of the inspection. Employee # 14 was due to have the communicable disease trainings no later than August 6, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Met with employee on 6/8/2022 to discuss training and supervision needs.
Discussed the difficulties of scheduling particular trainings through the website.
Employee will complete HIV/AIDS training immediately.
Clinical Director will monitor for training compliance. Each quarter, director will assess for outstanding trainings and reach out to staff individually for plan of action to get trainings completed.
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709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
709.17(a)(3) Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for an informed and voluntary consent form from the client for the disclosure of information were submitted and approved by the department for the July 9, 2021, December 8, 2020, and July 9, 2019 annual licensing inspections.
Obtaining an informed and voluntary consent form from the client for the disclosure of information were again found to be a deficiency in the June 1-3, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/6/2022, all initial appointments are scheduled as in-person visits. All consent forms for disclosure of information will be physically signed by clients.
Clinical Director will monitor on an ongoing basis with random chart audits.
Staff education was provided at weekly staff meeting on 6/8/2022 regarding confidentiality and the need for physical signatures before releasing any client specific information.
Clinical Director and Executive director met on 6/13/2022. Management team will monitor corrective active plans that are submitted and address aspects that are not being followed per the plan.
Changes to the consent process have been put immediately into place as to avoid the deficiency happening again. Clinical Director, along with management team, will evaluate the program on a quarterly basis to ascertain if POCs are not being followed as approved by the department.
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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 two of seven records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records #4 and # 7.
Client # 4 was admitted on March 16, 2022 and was still active at the time of the inspection. An authorization for funding occurred on March 16, 2022 however, there was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source.
Client # 7 was admitted on December 7, 2021 and was discharged on March 31, 2022. A review of progress notes indicated an interpreter was utilized for therapy sessions however, there was not an informed and voluntary consent from the client for the disclosure of information in the client record to an interpreter.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 9, 2021, December 8, 2020, and July 9, 2019 annual licensing inspection.
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Plan of Correction
Staff education was provided on 6/8/2022 regarding confidentiality and the importance of client signature on informed and voluntary consent forms.
Clinical Director will monitor on an ongoing basis with random chart audits
All initial appointments for drug and alcohol clients will be held in-person as to ensure client signature on release of information forms.
Facility will also utilize Docusign, for instances when the client cannot physically be in the building.
Information will not be released without a signed consent on file. Before releasing any protected information, clinicians are expected to check that consents are signed and up to date.
Director will randomly select charts to audit on a monthly basis to ensure that consents are signed and information is not being released outside of that consent or timeframe. |
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 four of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated signature of the client but instead had "verbal" in the client signature line.
Client # 1 was admitted on March 22, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated March 22, 2022 to a funding agency and probation officer did not have a valid signature by the client but instead had "verbal" in the signature line.
Client # 2 was admitted on January 5, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated January 14, 2022 to a funding agency and health care provider did not have a valid signature by the client but instead had "verbal" in the signature line.
Client # 5 was admitted on June 1, 2021 and was discharged July 15, 2021. An informed and voluntary consent from the client for the disclosure of information dated June 21, 2021 to a funding agency and emergency contact did not have a valid signature by the client but instead had "verbal" in the signature line.
Client # 7 was admitted on December 7, 2021 and was discharged March 31, 2022. An informed and voluntary consent from the client for the disclosure of information dated December 27, 2021 to a primary care physician did not have a valid signature by the client but instead had "verbal" in the signature line.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 9, 2021 annual licensing inspection.
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Plan of Correction
Staff education was provided on 6/8/2022 regarding confidentiality and the importance of client signature on informed and voluntary consent forms.
Clinical Director will monitor on an ongoing basis with random chart audits
Informed and voluntary consents will be added to the facility's compliance plan. |
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 two of three applicable client records reviewed, the facility failed to provide a complete client record to include case consultation notes in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate case consultations to occur at least quarterly for the first year of service.
Client # 2 was admitted on January 5, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than April 5, 2022. There were no case consultations documented in the client record.
Client # 3 was admitted on December 10, 2021 and was still active at the time of the inspection. A case consultation was due to occur no later than March 10, 2022. There were no case consultations documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff education was provided on 6/8/2022 regarding timelines and policy on case consultations.
In electronic system, as of 6/7/2022, all staff must document the last date that a case consultation was completed before they can sign off on the progress note for that date of service.
Clinical Director will monitor on an ongoing basis for compliance with regular chart audits.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on one of one applicable client record reviewed, the facility failed to provide an aftercare plan for a successfully discharged client.
Client # 7 was admitted on December 7, 2021 and was successfully discharged on March 31, 2022. There was no aftercare plan documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff education was provided on 6/8/2022 regarding aftercare planning and the importance of client involvement in such.
Clinical Director will monitor on an ongoing basis for compliance with regular chart audits.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on one of three applicable client records reviewed, the facility failed to provide a discharge summary within seven days of discharge in accordance with the facility policy and procedure manual.
Client # 6 was admitted on January 11, 2022 and was discharged on February 2, 2022. There was no discharge summary documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff education was provided on 6/8/2022 regarding discharge summaries and the need for summaries to be completed within 7 days of discharge in compliance with policy and regulations.
Clinical Director will monitor on an ongoing basis for compliance.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on two of two applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facilities policy and procedure manual. The facility policy and procedure manual indicated follow-up information to occur sixty days after discharge by letter.
Client # 5 was admitted on June 1, 2021 and discharged on July 15, 2021. A follow-up was due to occur no later than September 15, 2021. There was no documentation of follow-up information in the client record.
Client # 6 was admitted on January 1, 2022 and discharged on February 2, 2022. A follow-up was due to occur no later than April 2, 2022. There was no documentation of follow-up information in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 9, 2021 annual licensing inspection.
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Plan of Correction
Staff education was provided on 6/8/2022 regarding follow up contact with clients who have been discharged. Reiterated facility policy and the importance of follow up for continuity of care and regulatory compliance.
Clinical Director will monitor on an ongoing basis for compliance.
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