INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 6-9, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Diakon Family Life Services 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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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 two of six personnel records reviewed, the facility failed to provide documentation of an annual written individual staff performance evaluations that are reviewed and signed by the employee for employees # 5 and # 6.
Employee # 5 was hired as a counselor on February 11, 2019 and was still in this position at the time of the inspection. An annual performance evaluation occurred on January 10, 2020. The next performance evaluation was due to occur no later than January 10, 2021. There was no documentation of a performance evaluation in the personnel record.
Employee # 6 was hired as a counselor on January 21, 2019 and was still in this position at the time of the inspection. An annual performance evaluation occurred on May 21, 2020. The next performance evaluation was due to occur no later than May 21, 2021. There was no documentation of a performance evaluation in the personnel record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 14, 2020 part 1 annual licensing inspection.
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Plan of Correction
Employee #5 and #6 annual written individual staff performance evaluations will be completed by the Executive Director. Copies of which shall be reviewed and signed by the employee. This will be in compliance effective 8/2/2021. Compliance with this standard will be monitored and enforced by the Facility Director moving forward. |
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 five 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 the dated signature of the client. Informed and voluntary consent forms from the client were completed on behalf of the client from staff and only indicated a verbal consent from the client in client records # 2, 3, 4, 5, and 6.
Client # 2 was admitted on February 10, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a PCP, Other agency, and emergency contact had a dated signature of a witness however, it only contained a verbal telehealth consent by the client.
Client # 3 was admitted on March 24, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a funding source, and another agency had a dated signature of a witness however, it only contained a verbal telehealth consent by the client.
Client # 4 was admitted on March 17, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a funding source had a dated signature of a witness however, it only contained a verbal telehealth consent by the client.
Client # 5 was admitted on March 22, 2021 and was discharged on April 5, 2021. An informed and voluntary consent from the client for the disclosure of information to a funding source and Emergency contact had a dated signature of a witness however, it only contained a verbal telehealth consent by the client.
Client # 6 was admitted on March 9, 2021 and was discharged on June 28, 2021. An informed and voluntary consent from the client for the disclosure of information to a funding source and Emergency contact had a dated signature of a witness however, it only contained a verbal telehealth consent by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Whereby telehealth is done 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). When verbal consent is given during a telehealth session the clinical staff person will follow up with a written consent prior to the release of confidential client information. This will be in compliance effective 8/2/2021. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality review and supervision. |
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 three of four applicable client records reviewed, the facility failed to provide documentation of treatment and rehabilitation plans being reviewed and updated at least every 60 days in client records # 1, 2, and 7.
Client # 1 was admitted on March 3, 2021 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on April 28, 2021. A treatment and rehabilitation plan update was due no later than June 28, 2021. There was no documentation of a treatment and rehabilitation plan update in the client record.
Client # 2 was admitted on February 10, 2021 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on February 10, 2021. A treatment and rehabilitation plan update was due no later than April 10, 2021. There was no documentation of a treatment and rehabilitation plan update in the client record.
Client # 7 was admitted on January 27, 2021 and was discharged on June 10, 2021. A treatment and rehabilitation plan was developed on January 27, 2021. A treatment and rehabilitation plan update was due no later than March 27, 2021. There was no documentation of a treatment and rehabilitation plan update in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical staff will assure treatment and rehabilitation plans shall be reviewed and updated with the client at least every 60 days per Diakon Family Life Service's policy. This will be in compliance effective 8/2/2021. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality review and supervision. |
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 four of seven client records reviewed, the facility failed to provide documentation of counseling services being provided according to the individual treatment and rehabilitation plan, in client records # 1, 2, 3, and 7.
Client # 1 was admitted on March 3, 2021 and was still active at the time of the inspection. A treatment and rehabilitation plan developed on March 3, 2021 and updated on April 28, 2021 indicated 1-2 individual sessions to occur weekly. A review of progress notes and record of service documents only 1 individual session on June 14, 2021.
Client # 2 was admitted on February 10, 2021 and was still active at the time of the inspection. A treatment and rehabilitation plan developed on February 10, 2021 and indicated individual sessions to occur weekly. A review of progress notes and record of service documents only 1 individual session on February 10, 2021.
Client # 3 was admitted on March 24, 2021 and was still active at the time of the inspection. A treatment and rehabilitation plan developed on March 24, 2021 and May 27, 2021 indicated individual sessions to occur weekly. A review of progress notes and record of service documents only 1 individual session on May 27, 2021 and June 8, 2021.
Client # 7 was admitted on January 27, 2021 and was discharged on June 10, 2021. A treatment and rehabilitation plan developed on January 27, 2021 and indicated individual sessions to occur weekly. A review of progress notes and record of service shows no documentation of individual sessions in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical staff shall assure that counseling services are provided according to the individual treatment and rehabilitation plan. The clinical staff will follow treatment plan recommendations regarding frequency of treatment. This will be in compliance effective immediately. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality review and supervision. |
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 five of seven 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 February 10, 2021 and was still active at the time of the inspection. A case consultation was due to occur no later than May 10, 2021. There were no case consultations documented in the client record.
Client # 3 was admitted on March 24, 2021 and was still active at the time of the inspection. A case consultation was due to occur no later than June 24, 2021. There were no case consultations documented in the client record.
Client # 4 was admitted on March 17, 2021 and was still active at the time of the inspection. A case consultation was due to occur no later than June 17, 2021. There were no case consultations documented in the client record.
Client # 5 was admitted on March 22, 2021 and was discharged on April 5, 2021. A case consultation was due to occur no later than June 22, 2021. There were no case consultations documented in the client record.
Client # 7 was admitted on January 27, 2021 and was discharged on June 10, 2021. A case consultation was due to occur no later than April 27, 2021. 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
The clinical staff shall assure a complete client record 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. The clinical staff will complete case consultations at Intake and at least every 90 days per Diakon Family Life Service's policy. Case consultations will be reviewed and signed off on by the immediate supervisor. This will be in compliance effective 8/2/2021. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality review and supervision. |
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 complete client record to include a discharge summary in client record # 5.
Client # 5 was admitted on March 22, 2021 and discharged on April 5, 2021. There was no documentation of a discharge summary in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical staff shall assure 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. The clinical staff will complete a discharge summary within 5 days of a client being discharged from treatment. Discharge summaries will be reviewed and signed off on by the immediate supervisor. This will be in compliance effective 8/2/2021. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality review and supervision. |
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 one of one applicable client records reviewed, the facility failed to provide a complete client record to include follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within ninety days and six months.
Client # 5 was admitted on March 22, 2021 and discharged on April 5, 2021. There was no documentation of follow-up information in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical staff shall assure 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. It is the responsibility of the clinical staff person to make an attempt to follow up on a client's status after being discharged from the program. The clinical staff will complete follow up per Diakon Family Life Service's policy. This will be in compliance effective 8/2/2021. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality review and supervision. |