INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 17, 2023 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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709.30 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.
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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 all the regulatory client rights in seven of seven applicable client records reviewed.
Every applicable client record reviewed had a client handbook form, which was signed by the client indicating they received a copy of the client handbook, which included the client rights; however, the client rights in the handbook did not include all six required regulatory rights.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Quality Assurance updated Client Rights to include all six required regulatory rights. New handbooks were printed with updated client rights. |
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 December 2022 through October 2023 unusual incident logs, the facility failed to notify the Department within 3 business days of the offsite death of an active client.
The facility was made aware of the off-site death of a client on February 21, 2023; however, the incident was not reported to the Department until March 17, 2023.
This finding was reviewed with project and facility staff during the licensing process.
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Plan of Correction
Staff meeting with held on 11/21/20223 to address findings from DDAP audit. Staff was reminded of the importance of notifying DDAP within 3 business days of a death of an active client. Incident Report policy was redistributed to staff on 12/20/23. A quarterly PQI risk committee meeting is held to review all agency incident reports and timeliness will continue to be addressed. In addition, chart peer reviews are completed monthly to check for any missing/late documentation. |
709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's December 2022 through October 2023 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility.
There was an incident at the facility that required the presence of police and/or ambulance personnel at the facility on October 20, 2023; however, the incident was not reported to the Department at the time of the inspection.
This finding was reviewed with project and facility staff during the licensing process.
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Plan of Correction
Staff meeting with held on 11/21/20223 to address findings from DDAP audit. Staff was reminded of the importance of notifying DDAP within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility. Incident Report policy was redistributed to staff on 12/20/23. A quarterly PQI risk committee meeting is held to review all agency incident reports and timeliness will continue to be addressed. In addition, chart peer reviews are completed monthly to check for any missing/late documentation. |
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 review and update treatment and rehabilitation plans at least every sixty days in three of seven applicable client records reviewed.
Client # 1 was admitted on June 23, 2023 and was still active at the time of the inspection. The individual treatment plan was completed on June 23, 2023 and the first update was due no later than August 23, 2023; however, the update completed on September 7, 2023. Additionally, a treatment plan update was completed on September 7, 2023 and the next update was due no later than November 7, 2023; however, the update was completed on November 14, 2023.
Client # 4 was admitted on January 25, 2023 and was discharged on November 6, 2023. A treatment plan update was completed on March 28, 2023 and the next update was due no later than May 28, 2023; however, the update was completed on September 28, 2023.
Client # 5 was admitted on February 3, 2023 and was discharged on September 11, 2023. A treatment plan update was completed on April 26, 2023 and the next update was due no later than June 26, 2023; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan timeliness was addressed with staff during meeting on 11/21/23. As client 1, 4 and 5 all belonged to same clinician, it will be addressed with him individually in supervision on 12/22/23. He will review treatment plan due dates with his supervisor during weekly supervision. |
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 completing 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 and December 12, 2022 annual licensing inspections. Not completing treatment plan updates within the regulatory timeframe was again found to be a deficiency in the November 17, 2023, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Peer Reviews are completed on a monthly basis to check for overall compliance. There will be continued education to staff on time frames related to documentation. To further assist in this area, the Data Analytics and System Manager will provide weekly reports to supervisors/clinicians which include all upcoming treatment plan due dates. |