INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 12, 2008 through February 14, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Service Association of Bucks County 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 and a plan of correction is due on March 19, 2008.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel and training records, the facility failed to document a complete individual training plan for seven of eight employees reviewed, #1, 2, 3, 4, 5, 6 and 8. The individual training plans did not identify the subject areas and potential resources for training.
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Plan of Correction
At a Clinical Supervisors' Meeting schedule for March 19, 2008, the Director of Clinical Services (DCS) will discuss our facility's non-compliance with 704.11(b)(1), Individual Training Plans and outline a Plan of Correction.
Plan of Correction: Beginning immediately, all individual staff training plans, in addition to identifying specific training needs, must also specifically identify the subject area, actual courses, facility in-services, outside conferences, and/or specific books/journals/articles which will address the identified training needs. The individual training plans must also provide timeframes, i.e. the dates of recommended courses, conferences, or in-services or the date by which to complete suggested readings.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records, the facility failed to document that alternate exit routes were used from June 2007 through January 2008.
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Plan of Correction
On February 15, 2008 Director of Clinical Services (DCS)met with the Langhorne Office Manage, who is the person responsible for initiating random monthly fire drills at the Langhorne site. The DCS reviewed the importance of using alternate, randomly selected exit routes during all subsequent fire drills, beginning with a fire drill to be scheduled during the time period March 10 to March 31, 2008.
On March 10, 2008, the DCS distributed a Memorandum outlining the new fire drill procedures. The Memorandum specifically informed staff that alternate, randomly selected exit routes will be used during all subsequent fire drills and that the Office Manager will use the pager system to announce the specific exit route and the gathering place outside the building.
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709.28(a)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(2) Staff access to client records.
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Observations
Based on a review of administrative policies and procedures, the facility failed to document a policy that included staff positions who have access to client records.
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Plan of Correction
By April 11, 2008 Director of Clinical Services (DCS)will expand Policy CS.08, Client Records (Maintenance, Retention, Disposition, Destruction) to specifically delineate, by title and position, staff which may have direct access to client records. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in four of four client records reviewed, #1, 2, 3 and 4. The psychosocial evaluations did not include an assessment of the client's assets/strengths in two records, #2 and 3. The client's coping mechanisms beyond the client's drug and/or alcohol use was not addressed in four records, #1, 2, 3 and 4. The client's attitude towards and ability to participate in treatment was not assessed in three records, #1, 2 and 3.
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Plan of Correction
In a Behavioral Health Clinical Staff Meeting scheduled for March 26, 2008, the Director of Clinical Services (DCS) will review the importance of developing a comprehensive Psychosocial Evaluation which provides a clear, composite client profile. The DCS will emphasize that all assessments must specifically include and evaluation of the client's assets/strengths, must describe all of the client's coping mechanisms, and must discusses the client's attitude toward and ability to participate in treatment. Clinical Supervisors will monitor psychosocial assessments on an ongoing basis to ensure continued, consistent compliance with this regulatory standard. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document goals stated in terms of measurable criteria in three of four client records reviewed, #2, 3 and 4.
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Plan of Correction
In a Behavioral Health Clinical Staff Meeting scheduled for March 26, 2008, the Director of Clinical Services (DCS) will review Treatment Plan development. The DCS will specifically stress that goals must contain clear, measurable criteria and timeframes by which to assess progress. Clinical Supervisors will monitor Treatment Plans on an ongoing basis to ensure continued, consistent compliance with this regulatory standard. |
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 a review of client records, the facility failed to document complete treatment plan updates in two of four client records reviewed, #1 and 2. The last treatment plan update in client record #1 was completed on September 12, 2007 and did not have 60 day updates even though the client record was still open and active on February 14, 2008. The last treatment plan update in client record #2 did not provide an assessment of the client's progress for each goal from the prior treatment plan.
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Plan of Correction
In a Behavioral Health Clinical Staff Meeting scheduled for March 26, 2008, the Director of Clinical Services (DCS) will review Regulation 709.92(b) regarding timely completion of Treatment Plan Updates and stress the following:
1. Treatment Plan Updates must be completed at each 60-day interval even if a client has not attended treatment during a specific 60-day time period.
2. The Treatment Plan Updates should note the client's failure to attend, explain the attendance failure, and specify whether or not and for how long the record will remain open.
Clinical Supervisors will monitor Treatment Plan Updates on an ongoing basis to ensure continued, consistent compliance with this regulatory standard.
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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 a review of client records, the facility failed to document that counseling services were provided according to the individual treatment and rehabilitation plan in two of four client records reviewed, #1 and 2. The two clients were required to attend weekly individual treatment sessions, as per their treatment plans. Client record #1 showed that there was no documentation of treatment attended or any contacts made to the client from 10/23/07 to 2/5/08. Client record #2 showed that there was no documentation of treatment attended or any contacts made to the client from 8/29/07 to 9/26/07 and again from 12/5/07 to 1/2/08.
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Plan of Correction
In a Behavioral Health Clinical Staff Meeting scheduled for March 26, 2008, the Director of Clinical Services (DCS) will review Regulation 709.92(c)and will stress the following:
1. Counseling Services must be provided in accordance with the individual Treatment Plan.
2. Failure to adhere to the Treatment Plan, deviations from the Treatment Plan, and the reason(s) for the deviation must be explained and documented.
3. Documentation must explain any gaps in service, whether or not the record will remain open, and the plan for closing the record if applicable.
Clinical Supervisors will monitor Treatment Plans on an ongoing basis to ensure continued, consistent compliance with this regulatory standard.
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