INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1-3, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Diakon Child, Family and Community Ministries 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of employee # 3's personnel record, the facility failed to provide documentation of the core curriculum in clinical supervision training for clinical supervisors who have not functioned for two years as supervisors in the provision of clinical services.
Employee # 3 was promoted to a clinical supervisor position on August 16, 2021. There was no documentation of at least two years of supervision experience or the core curriculum training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Met with employee on 6/8/2022 to discuss supervision and training needs.
Employee will have core curriculum training completed immediately. Employee has had bi-weekly supervision in her current role and will continue to have supervision on an ongoing basis.
Clinical Director will monitor for training and supervision compliance.
Moving forward, employees seeking promotion will need to meet all requirements set forth by regulation for the position they are seeking PRIOR to submitting a transfer application to the new position.
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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 a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee # 3 received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee #3 was hired as a counselor on August 6, 2018 and promoted to clinical supervisor on August 16, 2021 and was still in this position at the time of the inspection. Employee # 3 was due to have the communicable disease trainings no later than August 6, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Met with employee on 6/8/2022 to discuss supervision and training needs.
Employee will complete HIV/AIDS training immediately.
Clinical Director will monitor for ongoing training compliance.
Moving forward, clinical director will monitor trainings on a quarterly basis. Director will reach out to clinicians individually for outstanding trainings and a work together on a plan to complete the training within the required timeframe.
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on two of four client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services.
Client # 1 was admitted on May 10, 2022 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on May 17, 2022 however, there was no documentation of type and frequency of services.
Client # 4 was admitted on May 13, 2021 and was discharged January 11, 2022. A comprehensive treatment and rehabilitation plan was developed with the client on October 5, 2021 however, there was no documentation of type and frequency of services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff education provided on 6/8/2022 regarding policy and regulations around treatment planning. Discussed the timeline of treatment plan development and review. Discussed the importance of documentation if treatment plan is late or going to be late.
Clinical Director will monitor for timeliness on treatment plans.
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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 three of three applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records # 2, 3 and # 4.
Client # 2 was admitted on March 8, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on March 8, 2022. A treatment and rehabilitation plan update was due no later than May 8, 2022 however, there was no documentation of a treatment plan update in the client record.
Client # 3 was admitted on March 30, 2021 and was discharged on January 11, 2022. A treatment and rehabilitation plan was developed on April 14, 2021. Treatment and rehabilitation plan updates were due no June 14, August 14, October 14, and December 14, 2021 however, there was no documentation of a treatment plan update in the client record.
Client # 4 was admitted on May 13, 2021 and was discharged on January 11, 2022. A treatment and rehabilitation plan was developed on October 5, 2021. A treatment and rehabilitation plan update was due no later than December 5, 2021 however, there was no documentation of a treatment plan update in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff education provided on 6/8/2022 regarding policy and regulations around treatment planning. Discussed the timeline of treatment plan development and review. Discussed the importance of documentation if treatment plan is late or going to be late.
Clinical Director will monitor for timeliness on treatment plans.
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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 two of two applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated follow-up information to occur sixty days after discharge by letter.
Client # 3 was admitted on March 30, 2021 and was discharged on January 11, 2022. A follow-up was due to occur no later than March 11, 2022. There was no documentation of follow-up information in the client record.
Client # 4 was admitted on May 13, 2021 and was discharged on January 11, 2022. A follow-up was due to occur no later than March 11, 2022. 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
Staff education was provided on 6/8/2022 regarding follow up contact with clients who have been discharged. Reiterated facility policy and the importance of follow up for continuity of care and regulatory compliance.
Clinical Director will monitor on an ongoing basis for compliance.
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