INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 9, 2020 through January 10, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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(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
The facility failed to provide documentation that all staff persons received the minimum of four hours of TB/STD training within the regulatory timeframe in one of thirteen employee files reviewed.
Employee #12 was hired as a counselor on February 20, 2018 and was due to have 4 hours of TB/STD training no later than February 20, 2019. The personnel record contained documentation of 2 hours of STD training but zero hours of TB training as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director re-trained Human Resources staff on the TB/STD and HIV requirements.
The Human Resources Manager will double-check training certificates for the correct number of hours before they are marked complete on the tracking sheet.
Employee #12 is registered for the STD/TB training scheduled for March 6, 2020.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
The facility failed to document the completion of 25 clock hours of annual training required for counselors during the facility's July 1, 2018 through June 30, 2019 training year in one of thirteen employee files.
Employee # 12 was hired as a counselor on February 20, 2018. The employee file documented 6 hours of annual training.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Human Resources Manager and Clinical Director will establish a policy requiring clinicians to obtain at least half their hours midway throughout the year. The current tracking system will be modified to better track trainings throughout the year. If staff are not on track for completing trainings, they will be subject to disciplinary action.
Employee # 12 will receive a written warning that will be placed in her HR file. Employee will be required to complete the 19 training hours missing during the facility's July 1, 2018 through June 30, 2019 training year. This is in addition to the 25 hours needed to complete July 1, 2019 through June 30, 2020 training yet.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document, on their fire drill log, the amount of people that were in the facility at the time of the drill during the April 2019 fire drill. This was discovered based on the review of the January 2019 through December 2019 fire drill logs.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facilities Coordinator will check that fire drill logs are filled out appropriately after each fire drill. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
The facility failed to document the specific information to be released on consent to release information forms in two of seven client records reviewed.
Client # 1 was admitted on November 7, 2019 and was active at the time of inspection. The release of information form to an emergency contact was signed and dated by the client on October 1, 2019.
Client # 5 was admitted on June 3, 2019 and was discharged on September 20, 2019. The release of information form to an emergency contact was signed and dated by the client on June 6, 2019.
These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Clinical Director and Clinical Supervisors will provide training in February to front desk, intake and clinicians on filling out releases.
Clinical Supervisors will review a random sample of charts each month (at least 5 for each clinician) for proper completion of releases.
Proper completion of releases is also reviewed quarterly through the peer review process.
If client # 1 is still active, a new emergency contact release will be obtained.
If client #5 is still active, a new emergency contact release will be obtained.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
The facility failed to document the purpose of disclosure on consent to release information forms in three of seven client records reviewed.
Client # 1 was admitted on November 7, 2019 and was active at the time of inspection. The release of information forms to various other treatment providers were signed and dated by the client on November 7, 2019.
Client # 2 was admitted on November 30, 2018 and was active at the time of inspection. The release of information form to another treatment provider was signed and dated by the client on December 4, 2019.
Client # 5 was admitted on June 3, 2019 and was discharged on September 20, 2019. The release of information form to an emergency contact was signed and dated by the client on June 6, 2019.
These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Clinical Director and Clinical Supervisors will provide training in February to front desk, intake and clinicians on filling out releases.
Clinical Supervisors will review a random sample of charts each month (at least 5 for each clinician) for proper completion of releases.
Proper completion of releases is also reviewed quarterly through the peer review process.
If client # 1 is still active, a new release will be obtained for the other treatment providers.
If client # 2 is still active, a new release will be obtained for the other treatment provider.
If client #5 is still active, a new emergency contact release will be obtained.
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
The facility failed to document a date, event, or condition on which the consent would expire on consent to release information forms in two of seven client records reviewed.
Client # 2 was admitted on November 30, 2018 and was active at the time of inspection. The release of information forms to the funding source and another treatment provider were signed and dated by the client on December 4, 2019.
Client # 5 was admitted on June 3, 2019 and was discharged on September 20, 2019. The release of information form to another treatment provider was signed and dated by the client on June 6, 2019.
These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Clinical Director and Clinical Supervisors will provide training in February to front desk, intake and clinicians on filling out releases.
Clinical Supervisors will review a random sample of charts each month (at least 5 for each clinician) for proper completion of releases.
Proper completion of releases is also reviewed quarterly through the peer review process.
If client # 2 is still active, a new release will be obtained for the funding source.
If client # 5 is still active, a new release will be obtained for the other treatment provider.
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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
The facility failed to document in writing that the clients acknowledged that when they are receiving care or treatment under section 7 of the act (71 P. S. 1690.107), they shall retain all their civil rights and liberties except as provided by statute 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 November 7, 2019 and was still active at the time of the inspection.
Client #2 was admitted on November 30, 2019 and was still active at the time of the inspection.
Client #3 was admitted on June 6, 2019 and was still active at the time of the inspection.
Client #4 was admitted on January 31, 2019 and was discharged on July 11, 2019.
Client # 5 was admitted on June 3, 2019 and was discharged on September 20, 2019.
Client # 6 was admitted on February 11, 2019 and was discharged on November 7, 2019.
Client #7 was admitted on July 18, 2018, 2019 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will revise the Welcome Packet Client Rights section to include the client right to retaining all their civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment.
If Client # 1 is still active when the welcome packet is revised, they will be given the revised welcome packet and will be asked to sign-off on the receipt form.
If Client # 2 is still active when the welcome packet is revised, they will be given the revised welcome packet and will be asked to sign-off on the receipt form.
If Client # 3 is still active when the welcome packet is revised, they will be given the revised welcome packet and will be asked to sign-off on the receipt form.
If Client # 4 returns for service, they will be given the revised welcome packet and will be asked to sign-off on the receipt form.
If Client # 5 returns for service, they will be given the revised welcome packet and will be asked to sign-off on the receipt form.
If Client # 6 returns for service, they will be given the revised welcome packet and will be asked to sign-off on the receipt form.
If Client # 7 is still active when the welcome packet is revised, they will be given the revised welcome packet and will be asked to sign-off on the receipt form.
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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
The facility failed to document in writing that the clients acknowledged that all clients have the right to submit rebuttal data or memoranda to their own records in seven of seven client records reviewed.
Client #1 was admitted on November 7, 2019 and was still active at the time of the inspection.
Client #2 was admitted on November 30, 2019 and was still active at the time of the inspection.
Client #3 was admitted on June 6, 2019 and was still active at the time of the inspection.
Client #4 was admitted on January 31, 2019 and was discharged on July 11, 2019.
Client # 5 was admitted on June 3, 2019 and was discharged on September 20, 2019.
Client # 6 was admitted on February 11, 2019 and was discharged on November 7, 2019.
Client #7 was admitted on July 18, 2018, 2019 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will revise the Welcome Packet Client Rights section to include the right that all clients to submit rebuttal data or memoranda to their own records.
If Client # 1 is still active when the welcome packet is revised, they will be given the revised welcome packet and will be asked to sign-off on the receipt form.
If Client # 2 is still active when the welcome packet is revised, they will be given the revised welcome packet and will be asked to sign-off on the receipt form.
If Client # 3 is still active when the welcome packet is revised, they will be given the revised welcome packet and will be asked to sign-off on the receipt form.
If Client # 4 returns for service, they will be given the revised welcome packet and will be asked to sign-off on the receipt form.
If Client # 5 returns for service, they will be given the revised welcome packet and will be asked to sign-off on the receipt form.
If Client # 6 returns for service, they will be given the revised welcome packet and will be asked to sign-off on the receipt form.
If Client # 7 is still active when the welcome packet is revised, they will be given the revised welcome packet and will be asked to sign-off on the receipt form.
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709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
The facility failed to develop and implement written reporting of unusual incident policies and procedures, within their unusual incident policy, how the facility would respond to the selling or use of illicit drugs on the premises.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Quality Improvement will revise the incident policy to include a procedure on how the agency will respond to the selling or use of illicit drugs on the premises. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
The facility failed to include, in their unusual incident policy, written procedures to follow regarding the implementation of a timely and appropriate corrective action plan following an unusual incident.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Quality Improvement will rise the incident policy to include a procedure on how the agency will implement a timely and appropriate corrective action plan following an unusual incident. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
The facility failed to include, in their unusual incident policy, written procedures to follow regarding the ongoing monitoring of the corrective action plan.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Quality Improvement will revise the incident policy to include a procedure on how the agency will monitor the corrective action plan ongoing. |
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
The facility failed to provide treatment plan updates within the regulatory timeframe in four of six applicable client records reviewed.
Client #2 was admitted on November 30, 2018 and was still active at the time of the inspection. A treatment plan update was completed on October 24, 2019 with an update due no later than December 24, 2019; however, the treatment plan update was not completed at the time of the inspection.
Client #4 was admitted on January 31, 2019 and was discharged on July 11, 2019. A treatment plan update was completed on March 27, 2019 with an update due no later than May 27, 2019; however, an update was not completed prior to discharge.
Client # 5 was admitted on June 3, 2019 and was discharged on September 20, 2019. The comprehensive treatment plan was completed on June 3, 2019 with an update due no later than August 3, 2019; however, an update was not completed prior to discharge.
Client #6 was admitted on February 11, 2019 and was discharged on November 7, 2019. A treatment plan was completed on April 25, 2019 with an update due no later than June 25, 2019; however, an update was not completed until October 18, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisors will provide training on treatment plans in February 2020 and June 2020.
Clinical Supervisors will review a random sample of charts each month (at least 5 for each clinician) for timeliness of treatment plans. Supervisors will assist clinicians having difficulty by instituting tracking grids/reminders for those clinicians.
Completion of timely treatment plans is also reviewed quarterly through the peer review process.
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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
The facility failed to maintain a complete client record on individuals, which is to include case consultations every 90 days, as required by the facility's written policy and procedures, in four of six applicable client records reviewed.
Client #2 was admitted on November 30, 2018 and was still active at the time of the inspection. There was record of a 90-day case consultation on March 28, 2019 with another case consultation due June 28, 2019; however, there were no additional case consultations at the time of the inspection.
Client #3 was admitted on June 6, 2019 and was still active at the time of the inspection. There was no record of a 90-day case consultation.
Client # 4 was admitted on January 31, 2019 and was discharged on July 11, 2019. There was no record of a 90-day case consultation.
Client # 6 was admitted on February 11, 2019 and was discharged on November 7, 2019. There was no record of a 90-day case consultation.
Client #7 was admitted on July 18, 2018 and was still active at the time of the inspection. There was record of a 90-day case consultation on May 5, 2019 with another case consultation due on August 5, 2019; however, there were no additional case consultations at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisors will provide training on 90 day/ treatment consults and the follow-up process in February 2020 and June 2020.
Clinical Supervisors will review a random sample of charts each month (at least 5 for each clinician) for 90 day consults and the follow-up process to monitor for completion of these items.
Completion of 90 day consults is also reviewed quarterly through the peer review process.
If client # 2 is still active, a 90-day consultation will be entered into the client's record.
If client # 3 is still active, a 90-day consultation will be entered into the client record.
If client # 7 is still active, a 90-day consultation will be entered into the client record.
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