INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 30, 2023 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 a review of personnel records, the facility failed to document that each staff receive an annual written individual performance evaluation on one out of three applicable records.
Employee #2, who was hired as a Facility Director on September 1, 2016, did not have an annual evaluation completed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.26 b3 The Project and Facility Director will assure each staff receive an annual written individual performance evaluation. At the time of inspection, the Facility Director was on FMLA and could not locate her most current signed performance eval. Upon her return on 7/10/23, it was located. This will be in compliance effective 7/12/2023. Compliance with this standard will be monitored and enforced by the Project Director, Facility Director and Clinical Coordinator through staff meetings 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 a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven records reviewed.
Client #1 was admitted on December 19, 2022 and was still active at the time of the inspection. A treatment plan update was completed on February 21, 2023 and the next update was due no later than April 21, 2023; however, it was not completed until June 1, 2023.
Client #3 was admitted on May 3, 2022 and was still active at the time of the inspection. A treatment plan update was completed on January 5, 2023 and the next update was due no later than March 5, 2023; however, it was not completed until March 9, 2023.
Client #7 was admitted on August 30, 2022 and discharged on May 4, 2023. A comprehensive treatment plan was completed on August 30, 2022 and an update was due no later than October 30, 2022; however, no update was completed.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 3, 2022 and July 9, 2021 licensing inspection.
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Plan of Correction
709.92 b The clinical staff will assure treatment and rehabilitation plans shall be reviewed and updated at least every 60 days per Diakon Family Life Service's policy. If the client is not present for the review/development of a treatment plan review the clinical staff will develop the treatment plan update and review with client at next attended session. This will be in compliance effective 7/28/2023. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality reviews 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 a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in three out of six applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 90 days following admission.
Client #1 was admitted on December 19, 2022 and was still active at the time of the inspection. A case consultation was due by March 19, 2022; however, it was not completed until March 29, 2023.
Client #3 was admitted on admitted on May 3, 2022 was still active at the time of the inspection. A case consultation was completed on February 2, 2023 and the next one was due no later than May 2, 2023; however, none was completed.
Client #7 was admitted on August 30, 2022 and discharged on May 4, 2023. A case consultation was due on November 30, 2022; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.93 a8 The clinical staff will assure case consultations shall be completed every 90 days following admission, according to Diakon policy. This will be in compliance effective 7/28/2023. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality reviews and 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 treatment plan updates were submitted and approved by the Department for the June 3, 2022 and July 9, 2021 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the June 30, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.17 a3 Prior to this year's annual inspection the DDAP representatives enforced that the treatment plan updates were to be developed with the client. Since this year's DDAP representative explained the interpretation of regulation 709.92 (b) the clinical staff can assure that treatment and rehabilitation plans will be updated every 60 days per Diakon Family Life Service's policy. If the client is not present for the review/development of a treatment plan review the clinical staff will develop the treatment plan update and review with client at next attended session. See 709.92b plan of correction. |