INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 16, 2021 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(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 records, the facility failed to provide documentation of an individual training plan, appropriate to that employee's skill level and developed with input from both the employee and the supervisor, in four of fourteen personnel records reviewed.Employee #5 was hired as a counselor on February 20, 2018. The individual training plan was last completed on November 11, 2020, and the next annual individual training plan was due no later than November 11, 2021. Employee #7 was hired as a counselor on December 18, 2019. The individual training plan was completed on January 29, 2021; however, the plan was not signed by the employee and not developed with the input of the employee. Employee #8 was hired as a counselor on January 6, 2020. The individual training plan was completed on January 29, 2021; however, the plan was not signed by the employee and not developed with the input of the employee. Employee #14 was hired as a counselor on July 11, 2021. The individual training plan was completed on July 7, 2021; however, the plan was not signed by the employee and not developed with the input of the employee. Additionally, the individual training plan was not individualized and based on the employee's skill level. This is a repeat citation from the November 19, 2020 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Family Service has typically included training plans in employee performance evaluations. However we will introduce a process where new training plans for all clinicians will be completed collaboratively between the clinician and supervisor annually during the first two months (January and February) of each year. This will be implemented 1/3/22.
For Employee #5, a new training plan will be completed collaboratively between Employee #5 and supervisor by 1/14/22.
For Employee #7, Supervisor and employee will review former training plan and if in agreement, both will sign. If not, both will indicate this on former plan and initial. Both will create and sign a new annual plan together by 1/29/2022.
For Employee #8, Supervisor and employee will review former training plan and if in agreement, both will sign. If not, both will indicate this on former plan and initial. Both will create and sign a new annual plan together by 1/29/2022.
For Employee #14, Supervisor and employee will review, individualize and sign former training plan based on employee skill level. Both will create and sign a new annual plan together during the first two months of the year as per new process.
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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 the review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that all staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics within the regulatory timeframes in one of four applicable personnel records reviewed. Employee # 8 was hired as a counselor on January 6, 2020 and was due to receive the minimum of 6 hours of HIV/AIDS training and 4 hours of TB/STD training no later than January 6, 2021. The employee completed TB/STD training within the regulatory timeframe; however, there was no documentation of the completion of HIV/AIDS training as of the date of the inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
It is part of Family Service's normal onboarding practice to require 6-hour HIVAIDS and 4 hours of TB/STD training. Generally, we have accesses trainings though our County Department of Health or DDAP website.
Employee #8 was notified of 2 virtual DDAP Trainings available, hosted by BHETN on 1/12-1/13/22 and 2/17-2/18/22. She has reached out regarding the 2/17-2/18 training but has not yet heard back. Clinical Supervisor will support this employee in completing the HIV training. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the facility-submitted Staffing Requirement Facility Summary Report, the facility failed to ensure that the Full Time Equivalent (FTE) counselor caseload for counseling in outpatient programs did not exceed 35 active clients in five of ten counselors employed. Additionally, the facility's overall FTE counselor caseload for counseling in outpatient programs exceeded 35 to 1 active clients.The counselor FTE is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.Employee #6 was hired as a counselor on September 30, 2019 and was still employed at the time of the inspection. The ratio calculation was as follows: 20/37.50= .5333(FTE); 20/.5333= 37.50 which equals a client/counselor ratio of 37:1.Employee #8 was hired as a counselor on January 6, 2020 and was still employed at the time of the inspection. The ratio calculation was as follows: 3.50/37.50= .0933(FTE); 4/.0933= 42.87 which equals a client/counselor ratio of 42:1.Employee #9 was hired as a counselor on August 16, 2021 and was still employed at the time of inspection. The ratio calculation was as follows: 28/37.50= .7466(FTE); 35/.7466= 46.87 which equals a client/counselor ratio of 46:1.Employee #10 was hired as a counselor on August 10, 2020 and was still employed at the time of inspection. The ratio calculation was as follows: 25/37.50= .6666(FTE); 31/.6666= 46.50 which equals a client/counselor ratio of 46:1.Employee #12 was hired as a counselor on July 26, 2021 and was still employed at the time of inspection. The ratio calculation was as follows: 23/37.50= .6133(FTE); 27/.6133= 44.02 which equals a client/counselor ratio of 44:1.Additionally, the overall facility outpatient ratio calculation was as follows: 175.50/37.50= 4.68(FTE); 196/4.68= 41.88 which equals an overall client/counselor ratio of 41:1This is a repeat citation from the November 19, 2020 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Family Service makes every attempt to adhere to the DDAP prescribed client ratio for OP LOC, 35:1. No clinician has over 35 DDAP clients. However, we apparently need to adhere to a ratio rather than numbers and will make this change when assigning clients to caseloads effective 1/17/22.
The alternatives to admitting clients for therapy, when clinicians have met ratio limits, are to hire clinicians, place clients on a waiting list or transfer them to another facility. Family Service is continuously seeking therapists. During COVID, hiring has been a challenge in the behavioral health field, community-wide. Other providers are struggling with the same challenge in hiring and also have wait lists so transfers are also difficult, especially when Family Service is the chosen provider.
Supervisor will work with Employee #6 to see if there are two D&A clients ready for discharge and complete by 1/30/22 in order to adhere to the ratio. If not, Employee # 6 will give 2 newest D&A clients the choice of going on a waitlist for individual therapy or going to another provider by 1/30/22.
Employee #8 works 6.5 hours per week and sees 4 D&A clients. We believe the ratio should be 3.5/6.5 = .5384 (FTE); 4/.5384 = client/counselor ratio of 7.42. Assuming this is over what it should be, Supervisor will work with clinician to determine if 1-2 D&A clients can be discharged and complete discharges by 1/30/22. If not, clinician will offer newest 1-2 D&A clients the choice of going on a waitlist for individual therapy or going to another provider by 1/30/22.
Employee #9 has 35 D&A clients. In order to adhere to DDAP ratio, Supervisor will work with clinician to determine if approximately 9-10 D&A clients are ready for discharge and complete discharges by 1/30/22. If this is not the case, clinician will offer newest 9-10 D&A clients the choice of going on a waitlist for individual therapy or going to another provider by 1/30/22.
Employee #10 has 31 D&A clients. In order to adhere to DDAP ratio, Supervisor will work with clinician to determine if approximately 8 D&A clients are ready for discharge and complete discharges by 1/30/22. If not, clinician will offer newest 8 D&A clients choice of going on a waitlist for individual therapy or going to another provider by 1/30/22.
Employee #12 has 27 D&A clients. In order to adhere to DDAP ratio, Supervisor will work with clinician to determine if there are approximately 5 D&A clients ready for discharge and complete discharges by 1/30/22. If not, clinician will offer 5 newest D&A clients choice of going on a waitlist for individual therapy or going to another provider by 1/30/22.
Re: the facility, Family Service continues to work on hiring to meet client needs. We have another therapist starting soon. To adhere to the DDAP prescribed ratio currently, Family Service will ask reassign to available therapists and as needed, ask all incoming clients if they prefer to be placed on a wait list for therapy or go to another provider (when we are over ratio). If clients choose to remain with Family Service, they will be assigned to first available therapist or if they prefer, can wait to return to previously assigned therapist. Clients who choose to stay will be able to continue to participate in group therapy. We do not consider this to be best practice and are presenting this corrective action as a way to adhere to DDAP mandates while still providing the client with treatment.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document annual written individual staff performance evaluation, copies of which shall be reviewed and signed by the employee, in four of eight applicable personnel records reviewed. Employee #1 was hired as the Project Director on August 28, 2020. The annual written individual staff performance evaluation for the review period of January 1, 2021 through June 30, 2021 was not signed by the employee.Employee #5 was hired as a counselor on February 20, 2018. The last annual written individual staff performance evaluation was completed on November 11, 2020, and the next performance evaluation was due no later than November 11, 2021. Employee #7 was hired as a counselor on December 18, 2019. The annual written individual staff performance evaluation was completed on January 29, 2021; however, the performance evaluation was not signed by the employee. Employee #8 was hired as a counselor on January 6, 2020. The annual written individual staff performance evaluation was completed on January 29, 2021; however, the performance evaluation was not signed by the employee. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Family Service employee evaluations are done with the employee via an electronic system and sent to employee to sign, print and submit to HR. During the COVID-19 pandemic and currently, many clinicians are working virtually to prevent the spread of illness. This at times is a barrier to obtaining signatures. However we will correct this issue by completing evaluations in a timely manner and having them signed either via printed document or electronic signature.
Employee #1 and BOD President have both signed the Performance Evaluation. This is complete.
Supervisor will work with Employee #5 to complete and sign an evaluation by 1/14/22.
Supervisor will review previous performance evaluation with Employee #7 and obtain signature. Supervisor will work with Employee #7 on creating a new, signed annual performance evaluation by 1/30/22.
Supervisor will review previous performance evaluation with Employee #8 and obtain signature. Supervisor will work with Employee #8 on creating a new, signed annual performance evaluation.
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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 a review of client records, the facility failed to document the dated signature of the client on release of information forms in seven of seven client records reviewed. Client #1 was admitted on February 1, 2021 and was discharged on May 21, 2021. There were release of information forms to an emergency contact, a funding source, and a government agency that were signed and dated by the witness on February 1, 2021; however, none of the forms documented the dated signature of the client. Client #2 was admitted on January 19, 2021 and was discharged on October 13, 2021. There were release of information forms to an emergency contact, a funding source, and a government agency that were signed and dated by the witness on January 19, 2021; however, none of the forms documented the dated signature of the client.Client #3 was admitted on January 5, 2021 and was discharged on July 23, 2021. There were release of information forms to an emergency contact, a funding source, a crisis center, and a government agency that were signed and dated by the witness on January 5, 2021; however, none of the forms documented the dated signature of the client.Client #4 was admitted on March 8, 2021 and was discharged on September 21, 2021. There were release of information forms to an emergency contact, a funding source, and another treatment provider that were signed and dated by the witness on March 8, 2021; however, none of the forms documented the dated signature of the client. Additionally, there were release of information forms to three different treatment providers that were signed and dated by the witness on March 17, 2021; however, none of the forms documented the dated signature of the client. Client #5 was admitted on January 5, 2021 and was active at the time of inspection. There were release of information forms to a physician, a funding source, a crisis center, and another treatment agency that were signed and dated by the witness on January 5, 2021; however, none of the forms documented the dated signature of the client.Client #6 was admitted on January 29, 2021 and was active at the time of inspection. There were release of information forms to an emergency contact and a funding source that were signed and dated by the witness on January 29, 2021; however, neither form documented the dated signature of the client. Additionally, a release of information form to a physician was signed and dated by the witness on February 11, 2021; however, the form did not document the dated signature of the client. Also, a release of information form to a government agency was signed and dated by the witness on March 2, 2021; however, the form did not document the dated signature of the client. Client #7 was admitted on January 25, 2021 and was active at the time of inspection. There were release of information forms to an emergency contact and a funding source that were signed and dated by the witness on January 27, 2021; however, neither form documented the dated signature of the client. Additionally, a release of information form to a physician was signed and dated by the witness on May 14, 2021; however, the form did not document the dated signature of the client.This is a repeat citation from the November 19, 2020 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the practice of Family Service to obtain signed consent for treatment and releases of information from client and guardian, if indicated. During the COVID-19 Pandemic, services were primarily virtual. DHS Bulletins indicated we were able to enter "COVID" in place of a signature when obtaining client verbal consent to documents and services. DDAP did not provide guidance to contraindicate this so Family Service followed this practice through 9/30/21 when the PA Emergency Declaration was lifted. Updated Bulletins indicated we need to get live or electronic signatures for D&A client documents and services so we began to have clients come to facility to sign. Due to the ongoing COVID pandemic and new virus variants, this has been a barrier. We will implement a "signature" month for consent and releases of information in January 2022 to work on obtaining all live or electronic signatures and ensure documents are updated.
Client #1 was discharged on May 21, 2021so there is no corrective action to pursue.
Client #2 was discharged October 13, 2021 so there is no corrective action to pursue.
Client #3 was discharged July 23, 2021 so there is no corrective action to pursue.
Client #4 was discharged September 21, 2021 so there is no corrective action to pursue.
As mentioned, there was an Emergency Declaration for the State of PA due to COVID-19 and to prevent the spread of illness, the majority of services were provided virtually with client verbal consent to documents and services obtained. Family Service will implement a consent and release signature month, January 2022, to obtain new consents for Client #5 and all D&A clients.
Clinician will obtain new signed consents for Client #5 by 1/30/22.
Clinician will obtain new signed consents for Client #6 by 1/30/22.
Clinician will obtain new signed consents for Client #7 by 1/30/22.
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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
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified that a client receiving care of treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by status and that no client may be deprived of a civil right solely by reason of treatment in seven of seven client records reviewed. Client #1 was admitted on February 1, 2021 and was discharged on May 21, 2021.Client #2 was admitted on January 19, 2021 and was discharged on October 13, 2021.Client #3 was admitted on January 5, 2021 and was discharged on July 23, 2021.Client #4 was admitted on March 8, 2021 and was discharged on September 21, 2021.Client #5 was admitted on January 5, 2021 and was active at the time of inspection.Client #6 was admitted on January 29, 2021 and was active at the time of inspection.Client #7 was admitted on January 25, 2021 and was active at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Family Service notifies clients of their rights upon admission via Client Welcome Handbooks and Magellan rights. Clients generally sign that they have received their rights. During the COVID-19 Pandemic, services were primarily virtual. DHS Bulletins indicated we were able to enter "COVID" in place of a signature for documents and services. DDAP did not provide guidance to contraindicate this so Family Service followed this practice for clients receiving virtual services through 9/30/21 when the PA Emergency Declaration was lifted. Updated Bulletins instructed providers to get live or electronic signatures for D&A client documents and services so we began to have clients come to facility to sign. Due to the ongoing COVID pandemic and new virus variants, this has been challenging. We will implement a "signature" month for signing documents, including acknowledgment of receiving rights, in January 2022 to obtain all live or electronic signatures and ensure documents are updated.
Client #1 was discharged May 1, 2021 so there is no corrective action to pursue.
Client #2 was discharged October 13, 2021 so there is no corrective action to pursue.
Client #3 was discharged July 23, 2021 so there is no corrective action to pursue.
Client #4 was discharged September 21, 2021 so there is no corrective action to pursue.
Clinician will work with Client #5 to obtain new signature to acknowledge receipt of civil rights by 1/30/22.
Clinician will work with Client #6 to obtain new signature to acknowledge receipt of civil rights by 1/30/22.
Clinician will work with Client #7 to obtain new signature to acknowledge receipt of civil rights by 1/30/22.
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709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified that the project may not discriminate in the provision of services basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in seven of seven client records reviewed. Client #1 was admitted on February 1, 2021 and was discharged on May 21, 2021.Client #2 was admitted on January 19, 2021 and was discharged on October 13, 2021.Client #3 was admitted on January 5, 2021 and was discharged on July 23, 2021.Client #4 was admitted on March 8, 2021 and was discharged on September 21, 2021.Client #5 was admitted on January 5, 2021 and was active at the time of inspection.Client #6 was admitted on January 29, 2021 and was active at the time of inspection.Client #7 was admitted on January 25, 2021 and was active at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Family Service notifies clients of their rights upon admission via Client Welcome Handbooks and Magellan rights. Both include non-discrimination rights. Clients sign that they have received their rights. During the COVID-19 Pandemic, services were primarily virtual and clinicians obtained verbal consent and signed "COVID" for their clients. Getting clients to come in, due to the ongoing COVID pandemic and new virus variants, has been challenging.
We will implement a "signature" month for signing documents, including acknowledgment of receiving rights, in January 2022 to obtain all live or electronic signatures and ensure documents are updated.
Client #1 was discharged May 1, 2021 so there is no corrective action to pursue.
Client #2 was discharged October 13, 2021 so there is no corrective action to pursue.
Client #3 was discharged July 23, 2021 so there is no corrective action to pursue.
Client #4 was discharged September 21, 2021 so there is no corrective action to pursue.
Clinician will work with Client #5 to obtain new signature to acknowledge receipt of rights, including non-discrimination, by 1/30/22.
Clinician will work with Client #6 to obtain new signature to acknowledge receipt of rights, including non-discrimination, by 1/30/22.
Clinician will work with Client #7 to obtain new signature to acknowledge receipt of rights, including non-discrimination, by 1/30/22.
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709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they were notified that they have the right to inspect their own record and that the project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client in seven of seven client records reviewed. Client #1 was admitted on February 1, 2021 and was discharged on May 21, 2021.Client #2 was admitted on January 19, 2021 and was discharged on October 13, 2021.Client #3 was admitted on January 5, 2021 and was discharged on July 23, 2021.Client #4 was admitted on March 8, 2021 and was discharged on September 21, 2021.Client #5 was admitted on January 5, 2021 and was active at the time of inspection.Client #6 was admitted on January 29, 2021 and was active at the time of inspection.Client #7 was admitted on January 25, 2021 and was active at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Family Service notifies clients of their rights upon admission via Client Welcome Handbooks and Magellan rights. Clients sign that they have received their rights. During the COVID-19 Pandemic, services were primarily virtual and clinicians obtained verbal consent and signed "COVID" for their clients. Getting clients to come in, due to the ongoing COVID pandemic and new virus variants, has been challenging.
We will implement a "signature" month for signing documents, including acknowledgment of receiving rights, in January 2022 to obtain all live or electronic signatures and ensure documents are updated.
Client #1 was discharged May 1, 2021 so there is no corrective action to pursue.
Client #2 was discharged October 13, 2021 so there is no corrective action to pursue.
Client #3 was discharged July 23, 2021 so there is no corrective action to pursue.
Client #4 was discharged September 21, 2021 so there is no corrective action to pursue.
Clinician will work with Client #5 to obtain new signature to acknowledge receipt of rights, including right to inspect own record, by 1/30/22.
Clinician will work with Client #6 to obtain new signature to acknowledge receipt of rights, including right to inspect own record, by 1/30/22.
Clinician will work with Client #7 to obtain new signature to acknowledge receipt of rights, including right to inspect own record, by 1/30/22.
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709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director in seven of seven client records reviewed.Client #1 was admitted on February 1, 2021 and was discharged on May 21, 2021.Client #2 was admitted on January 19, 2021 and was discharged on October 13, 2021.Client #3 was admitted on January 5, 2021 and was discharged on July 23, 2021.Client #4 was admitted on March 8, 2021 and was discharged on September 21, 2021.Client #5 was admitted on January 5, 2021 and was active at the time of inspection.Client #6 was admitted on January 29, 2021 and was active at the time of inspection.Client #7 was admitted on January 25, 2021 and was active at the time of inspection. This is a repeat citation from the November 19, 2020 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Family Service notifies clients of their rights upon admission via Client Welcome Handbooks and Magellan rights. Clients sign that they have received their rights. During the COVID-19 Pandemic, services were primarily virtual and clinicians obtained verbal consent and signed "COVID" for their clients. Getting clients to come in, due to the ongoing COVID pandemic and new virus variants, has been challenging.
We will implement a "signature" month for signing documents, including acknowledgment of receiving rights, in January 2022 to obtain all live or electronic signatures and ensure documents are updated.
Client #1 was discharged May 1, 2021 so there is no corrective action to pursue.
Client #2 was discharged October 13, 2021 so there is no corrective action to pursue.
Client #3 was discharged July 23, 2021 so there is no corrective action to pursue.
Client #4 was discharged September 21, 2021 so there is no corrective action to pursue.
Clinician will work with Client #5 to obtain new signature to acknowledge receipt of rights, including right to appeal decisions limiting access to records, by 1/30/22.
Clinician will work with Client #6 to obtain new signature to acknowledge receipt of rights, including right to appeal decisions limiting access to records, by 1/30/22.
Clinician will work with Client #7 to obtain new signature to acknowledge receipt of rights, including right to appeal decisions limiting access to records, by 1/30/22.
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709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they had been informed of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in seven of seven client records reviewed.Client #1 was admitted on February 1, 2021 and was discharged on May 21, 2021.Client #2 was admitted on January 19, 2021 and was discharged on October 13, 2021.Client #3 was admitted on January 5, 2021 and was discharged on July 23, 2021.Client #4 was admitted on March 8, 2021 and was discharged on September 21, 2021.Client #5 was admitted on January 5, 2021 and was active at the time of inspection.Client #6 was admitted on January 29, 2021 and was active at the time of inspection.Client #7 was admitted on January 25, 2021 and was active at the time of inspection. This is a repeat citation from the November 19, 2020 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Family Service notifies clients of their rights upon admission via Client Welcome Handbooks and Magellan rights. Clients sign that they have received their rights. During the COVID-19 Pandemic, services were primarily virtual and clinicians obtained verbal consent and signed "COVID" for their clients. Getting clients to come to the site, due to the ongoing COVID pandemic and new virus variants, has been challenging.
We will implement a "signature" month for signing documents, including acknowledgment of receiving rights including right to request corrections to inaccurate, irrelevant, outdated or incomplete information, in January 2022 to obtain all live or electronic signatures and ensure documents are updated.
Client #1 was discharged May 1, 2021 so there is no corrective action to pursue.
Client #2 was discharged October 13, 2021 so there is no corrective action to pursue.
Client #3 was discharged July 23, 2021 so there is no corrective action to pursue.
Client #4 was discharged September 21, 2021 so there is no corrective action to pursue.
Clinician will work with Client #5 to obtain new signature to acknowledge receipt of rights, including right to correct information in their records, by 1/30/22.
Clinician will work with Client #6 to obtain new signature to acknowledge receipt of rights, including right to correct information in their records, by 1/30/22.
Clinician will work with Client #7 to obtain new signature to acknowledge receipt of rights including right to correct information in their records, by 1/30/22.
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709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they had been informed of their right to submit rebuttal data or memoranda to their own records in seven of seven client records reviewed.Client #1 was admitted on February 1, 2021 and was discharged on May 21, 2021.Client #2 was admitted on January 19, 2021 and was discharged on October 13, 2021.Client #3 was admitted on January 5, 2021 and was discharged on July 23, 2021.Client #4 was admitted on March 8, 2021 and was discharged on September 21, 2021.Client #5 was admitted on January 5, 2021 and was active at the time of inspection.Client #6 was admitted on January 29, 2021 and was active at the time of inspection.Client #7 was admitted on January 25, 2021 and was active at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Family Service notifies clients of their rights upon admission via Client Welcome Handbooks and Magellan rights. Clients sign that they have received their rights. During the COVID-19 Pandemic, services were primarily virtual and clinicians obtained verbal consent and signed "COVID" for their clients. Getting clients to come to the site, due to the ongoing COVID pandemic and new virus variants, has been challenging.
We will implement a "signature" month for signing documents, including acknowledgment of receiving rights including right to submit rebuttal data or memoranda to their records, in January 2022 to obtain all live or electronic signatures and ensure documents are updated.
Client #1 was discharged May 1, 2021, so there is no corrective action to pursue.
Client #2 was discharged October 13, 2021, so there is no corrective action to pursue.
Client #3 was discharged July 23, 2021, so there is no corrective action to pursue.
Client #4 was discharged September 21, 2021, so there is no corrective action to pursue.
Clinician will work with Client #5 to obtain new signature to acknowledge receipt of rights, including right to submit rebuttals, by 1/30/22.
Clinician will work with Client #6 to obtain new signature to acknowledge receipt of rights, including right to submit rebuttals, by 1/30/22.
Clinician will work with Client #7 to obtain new signature to acknowledge receipt of rights, including right to submit rebuttals, by 1/30/22.
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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of the facility's client list, the facility failed to notify the Department within 3 business days following an unusual incident involving the offsite death of a client. On November 12, 2021, the facility was notified of the death of a client. However, the facility failed to provide documentation that this incident was reported to the Department within 3 business days. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the policy and practice of Family Service to notify DDAP within 3 business days following an unusual incident, particularly when there is a death involved.
There is no corrective action to be pursued for this specific incident as it occurred in the past.
To re-educate/remind staff about timely filing of Incident Reports, Director of Quality Insurance will resend policy to all staff by 1/14/22.
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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 a review of client records, the facility failed to ensure that all treatment and rehabilitation plans were reviewed and updated at least every sixty days in five of seven client records reviewed.Client #3 was admitted on January 5, 2021 and was discharged on July 23, 2021. The comprehensive treatment plan was completed on January 13, 2021. The first update was due no later than March 13, 2021; however, the update was completed on April 5, 2021. Additionally, the next update was due no later than June 5, 2021, but there was no update completed prior to discharge. Client #4 was admitted on March 8, 2021 and was discharged on September 21, 2021. The comprehensive treatment plan was completed on March 16, 2021. The first update was due no later than May 16, 2021; however, the update was completed on June 14, 2021. Additionally, the next update was due no later than July 16, 2021, but there was no update completed prior to discharge.Client #5 was admitted on January 5, 2021 and was active at the time of inspection. A treatment plan update was completed on April 8, 2021. The next update was due no later than June 8, 2021; however, the update was completed on October 8, 2021. Additionally, the next update was due no later than December 8, 2021, but the update was completed on December 14, 2021.Client #6 was admitted on January 29, 2021 and was active at the time of inspection. A treatment plan update was completed on April 6, 2021. The next update was due no later than June 6, 2021; however, the update was completed on July 23, 2021. Additionally, the next update was due no later than September 23, 2021, but the update was completed on December 14, 2021.Client #7 was admitted on January 25, 2021 and was active at the time of inspection. The comprehensive treatment plan was completed on June 15, 2021. The first update was due no later than August 15, 2021; however, the update was completed on December 9, 2021.This is a repeat citation from the November 19, 2020 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
It is the policy of Family Service for clinicians to work collaboratively with clients in updating treatment plans at least every 60 days.
Updating treatment plans in a timely fashion is an ongoing challenge for a number of reasons. However, Family Service values collaborative treatment planning and is constantly working to improve processes for timely completion.
Clinical Supervisor has reviewed the need for treatment plan updates within 60 days with all clinicians. A notification trigger, which sends a notice to the counselor 10 days prior to treatment plan due date, has been added to the electronic health system to help address timely treatment plans.
For Client #3, Supervisor will review this report with assigned clinician to increase understanding of issue by 1/13/22. Client is discharged so there is no further corrective action.
For Client #4, Supervisor will review this report with assigned clinician to increase understanding of issue by 1/13/22. Client is discharged so there is no further corrective action,
For Client #5, Supervisor will review this report with assigned clinician to increase understanding of issue by 1/13/22. Client is discharged so there is no further corrective action.
Client #6 is still active. Supervisor will review this report with assigned clinician to increase understanding of issue by 1/13/22. Supervisor will monitor treatment plan due dates in regular Clinical supervision meetings.
Client #7 is still active. Supervisor will review this report with assigned clinician to increase understanding of issue by 1/13/22. Supervisor will monitor treatment plan due dates in regular Clinical supervision meetings.
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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 a review of client records, the facility failed to maintain a complete client record on an individual, which is to include follow-up information, in three of four applicable client records reviewed.Client #2 was admitted on January 19, 2021 and was discharged on October 13, 2021. The written procured manual stated that follow-up will be completed within 30 days of discharge. There was no follow-up information documented in the client record at the time of inspection. Client #3 was admitted on January 5, 2021 and was discharged on July 23, 2021. The written procured manual stated that follow-up will be completed within 30 days of discharge. There was no follow-up information documented in the client record at the time of inspection. Client #4 was admitted on March 8, 2021 and was discharged on September 21, 2021. The written procured manual stated that follow-up will be completed within 30 days of discharge. There was no follow-up information documented in the client record at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the policy of Family Service to provide a follow up contact, generally a call, within 30 days after discharge.
Supervisor will remind team of need to make follow up contact with all discharged clients in meeting on 1/13/22.
For Client #2, assigned clinician will make a follow up call and document results by 1/14/22.
For Client #3, assigned clinician will make a follow up call and document results by 1/14/22.
For Client #4, assigned clinician will make a follow up call and document results by 1/14/22.
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