INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 29-31, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, DARS Inc. Supervised Independent Living Programs 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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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
During a licensing inspection conducted on October 29-31, 2019, the facility failed to provide documentation of direct observation of a counselor assistant during the required close supervision period.
Employee # 5 was hired as a counselor assistant on June 17, 2019 and was still in this position at the time of the inspection and there was no documentation of direct observation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The DARS, Inc. SIL Program Director and Senior Counselor will insure that the necessary direct observation will be provided for the counselor assistant and documentation will be properly noted in the counselor assistant's training file. The Senior Counselor and or Program Director, in the Senior Counselor's absence, will see that direct observation is completed weekly for individual counseling sessions. It will be the Senior Counselor's primary responsibility and overseen by the SIL Program Director. |
709.26 (a) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(3) Supervision of staff.
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Observations
During a licensing inspection conducted on October 29-31, 2019, the governing body failed to adopt and implement written project personnel policies and procedures in compliance with State and Federal employment laws to include written policies and procedures related to supervision of staff.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will develop written policies and procedures regarding the Supervision of Staff. The updated manual reflecting the updates will be available for the next licensing visit. |
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
During a licensing inspection conducted on October 29-31, 2019, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information to a funding source in one of seven charts reviewed.
Client # 1 was admitted on June 13, 2019 and was still an active client at the time of the inspection. There was not an informed and voluntary consent from the client for the disclosure of information to a funding source in the client record.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
The DARS., Inc. SIL Program Director and Senior Counselor will provide supervision for the counselors/counselor assistants at client intake to oversee that all necessary confidentiality forms are completed in their entirety. Client # 1 was supervised by the Senior Counselor to reflect that the proper funding source consent, for disclosure of information, was client signed and dated. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
During a licensing inspection conducted on October 29-31, 2019, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for disclosures of information in client record #6.
Client # 6 was admitted on January 18, 2019 and discharged on April 16, 2019. An informed and voluntary consent to disclose information form signed and dated March 6, 2019 to a government agency, allowed the release of a phone record.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
The DARS.,Inc. Senior Counselor will oversee that client general consent forms are limited to the release of specific information according to confidentiality regulations. This will be executed during weekly chart reviews during staff meetings. Specifically, the Senior Counselor will insure that the client consent forms are properly completed to reflect the specific information disclosed is within the limits of 4 Pa. Code 255.5 (b). The SIL Program Director will oversee that the Senior Counselor is carrying out the plan of correction through monthly consultations. At no point in time will client phone records be documented within a consent form governed by 4 Pa. Code 255.5(b) for criminal investigations. All active criminal investigations requiring client phone records will need proper court intervention/subpoena. The consent form cited was voided by the SIL Program Director. |
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
During a licensing inspection conducted on October 29-31, 2019, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #5.
Client # 5 was admitted on January 28, 2019 and discharged on September 27, 2019. An informed and voluntary consent to disclose information form signed and dated January 28, 2019 to "Urgent Care", did not provide a purpose of release.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
The DARS., Inc. SIL Program Director and Senior Counselor will see that all General client consent forms (#66) will indicate a purpose for release. The Senior Counselor will supervise the client consent forms at client intake and insure that the purpose of release is properly documented on the form. The Program Director will oversee that the Senior Counselor is executing the plan of correction on a weekly basis. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
During a licensing inspection conducted on October 29-31, 2019, the project failed to develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights in client record # 2.
Client # 2 was admitted on June 26, 2019 and was still an active client at the time of the inspection. The client ' s rights acknowledgement form was missing the signature of the client.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The signature page of the client rights acknowledgment form was located during the review of the file. The DARS., Inc. Senior Counselor will see that all client charts are organized to reflect the Table of Contents located in Section # 1 of the chart.The Senior Counselor will meet weekly with clinical staff and their client charts to insure the charts are organized according to the table of contents. The SIL Program Director will oversee that this action is provided for with weekly consults with the Senior Counselor. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
During a licensing inspection conducted on October 29-31, 2019, the project failed to develop and implement policies and procedures for responding to a physical assault or sexual assault by staff or a client.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The policy and procedure regarding Unusual Incident of responding to a physical or sexual assault by staff or a client has been created. It will be available for the next licensing inspection. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
During a licensing inspection conducted on October 29-31, 2019 the project to develop and implement policies and procedures in responding to selling or use of illicit drugs on the premises.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The policy and procedure regarding the Unusual Incident of responding to selling or use of illicit drugs on the premises has been created. It will be available for the next licensing inspection. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
During a licensing inspection conducted on October 29-31, 2019, the project failed to develop and implement policies and procedures in responding to a death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The policy and procedure regarding the Unusual Incident of responding to a death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when know by facility for ambulatory services was created by the Program Director. It will be available for the next licensing inspection. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
During a licensing inspection conducted on October 29-31, 2019, the project failed to develop and implement policies and procedures in responding to theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The policy and procedure for responding to theft, burglary, break-in or similar incident at the facility was developed by the Program Director. It will be available at the next licensing visit. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a licensing inspection conducted on October 29-31, 2019, the project failed to develop and implement policies and procedures in responding to event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A policy and procedure for responding to the unusual incident of an event at the facility requiring police, fire or ambulance personnel was developed by the Program Director. The policy will be available for the next licensing visit. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
During a licensing inspection conducted on October 29-31, 2019, the project failed to develop and implement policies and procedures in responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The policy and procedure for the unusual incident of responding to an outbreak of contagious disease requiring Centers for Disease Control (CDC) notification was created by the Program Director. It will be available for the next licensing visit. |