INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 5, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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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, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health-related topics training within the regulatory timeframe in one of four applicable personnel record reviewed.
Employee # 4 was hired as a counselor on April 8, 2024 and was due to have the HIV/AIDS training and the TB/STD training completed no later than April 8, 2025. The HIV/AIDS training was documented as completed on April 19, 2025 and the TB/STD training was not completed at the time of the inspection.
This is a repeat citation from the October 29, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A new position was created to assist with tracking training hours for all staff- Quality Improvement and Training Specialist. In addition, all trainings are being uploaded into an online learning system to create an easier monitoring system.
There are currently no open trainings for TB/STD but Associate Director is looking weekly so staff can be signed up as soon as possible. |
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 a review of personnel records, the facility failed to ensure CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in CPR is onsite during the project's hours of operations.
At the time of the inspection, there was documentation provided indicating only one staff person had a current CPR certification.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Family Service will be offering a First Aid and CPR certification on site moving forward, which will be held twice a year. The first training will be held on January 8, 2026 and staff will be trained to ensure coverage for all hours of operations. Quality Improvement and Training Specialist will monitor staff training monthly to ensure ample CPR trained staff coverage. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's November 2024 through September 2025 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.
The facility's posted hours of operation are Monday through Wednesday from 8:30 a.m. to 8:00 p.m. and Thursday through Friday from 8:30 a.m. to 5:00 p.m. Every fire drill completed throughout the reviewed period was conducted during the morning hours. There were no fire drills conducted during the facility's afternoon or evening hours of operation.
This is a repeat citation from the October 29, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Family Service trained additional, evening staff to complete fire drills during all hours of operation. On 11/25/25, an evening drill was completed. The Facilities Maintenance Manager will rotate the schedule to ensure morning, afternoon and evening fire drills are completed.
Each month, the fire drills are uploaded into shared agency file and monitored by Director of Quality Assurance to ensure they are complete. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a release of information form in one of seven client records reviewed.
Client # 6 was admitted on April 7, 2025 and was discharged on September 17, 2025. The release of information form to a parole officer was signed by the client on April 7, 2025, but the form did not include documentation of the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
It was determined that the purpose of disclosure on ROI was an option that was not mandatory.
On 11/18/25, the purpose of disclosure option was made mandatory in EHR, so it will not be missed.
Monthly charts reviews will be completed by supervisory staff (10% of census each quarter), which includes monitoring ROIs are completed correctly. |
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 ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in six of seven client records reviewed.
Client # 1 was admitted on January 6, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 17, 2025 and the first update was due no later than March 17, 2025; however, the update was completed on March 28, 2025. Additionally, a treatment plan update was completed on August 13, 2025 and the next update was due no later than October 13, 2025; however, the update was not completed as of the date of the inspection.
Client # 2 was admitted on January 27, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 4, 2025 and the first update was due no later than April 4, 2025; however, the update was completed on April 22, 2025. Additionally, the next treatment plan was due no later than June 22, 2025; however, the update was completed on June 26, 2025.
Client # 3 was admitted on June 12, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 7, 2025 and the first update was due no later than September 7, 2025; however, the update was not completed as of the date of the inspection.
Client # 4 was admitted on March 7, 2025 and was discharged on October 10, 2025. The individual treatment and rehabilitation plan was completed on April 3, 2025 and the first update was due no later than June 3, 2025; however, the update was not completed prior to discharge.
Client # 6 was admitted on April 7, 2025 and was discharged on September 17, 2025. The individual treatment and rehabilitation plan was completed on May 8, 2025 and the first update was due no later than July 8, 2025; however, the update was completed on July 17, 2025.
Client # 7 was admitted on February 21, 2025 and was discharged on July 1, 2025. The individual treatment and rehabilitation plan was completed on February 21, 2025 and the first update was due no later than April 21, 2025; however, the update was not completed prior to discharge.
This is a repeat citation from the January 10, 2020, November 19, 2020, December 16, 2021, December 12, 2022, November 17, 2023, and October 29, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/20/25, the Outpatient Manager created a D&A and IOP treatment plan report that will go out monthly to clinicians. Each counselor was notified of late treatment plans and instructed to complete them immediately. The D&A clinical supervisor will send out and monitor this list at the beginning of each month, to ensure treatment plans are being completed on time.
Client 1 treatment plan update was completed on 11/12/25. Client 2 treatment plan update was completed on 12/19/25. Clients 3, 4, 6, and 7 have been discharged. |
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 a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include the documentation of case consultation notes per facility policy, in five of seven client records reviewed.
The facility policy and procedure manual states that case consultation notes are to be completed quarterly for the first year of treatment and annually thereafter.
Client # 1 was admitted on January 6, 2025 and was still active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 2 was admitted on January 27, 2025 and was still active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 4 was admitted on March 7, 2025 and was discharged on October 10, 2025. There were no case consultation notes documented in the record at the time of the inspection.
Client # 6 was admitted on April 7, 2025 and was discharged on September 17, 2025. There were no case consultation notes documented in the record at the time of the inspection.
Client # 7 was admitted on February 21, 2025 and was discharged on July 1, 2025. There were no case consultation notes documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
FSA policy states that case consultation notes will be completed quarterly. On 11/20/25, the Outpatient Manager completed a case consult report that will be run monthly. The D&A clinical Supervisor will send this out monthly to ensure that all consults are being completed as noted by policy.
Case consults for client 1 and client 2 were completed on 12/17/25. Client 4, 6, and 7 have been discharged. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(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.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to complete treatment plan updates within the regulatory timeframe was submitted and approved by the Department for the January 10, 2020, November 19, 2020, December 16, 2021, December 12, 2022, November 17, 2023, and October 29, 2024 annual licensing inspections. Failing to complete treatment plan updates within the regulatory timeframe was again found to be a deficiency in the November 5, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Different positions have been created in the agency to assist with oversight of D&A program: A D&A Counseling Assistant, Outpatient Manager, and Quality Improvement and Training Specialist. With this additional oversight and assistance, we will be better able to monitor previous programmatic concerns. |