INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 29-30, 2025 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 and Children's Aid Society of Venango 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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709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to complete initial treatment plans according to agency policy and procedure in three of seven records.
According to agency policy and procedures, the preliminary treatment plan is completed at intake, initial treatment plan is completed within 30 days, and all additional updates are done every 60 days thereafter.
Client #1 was admitted January 7, 2025 and discharged August 12, 2025. The client ' s initial treatment plan was due by February 6, 2025 but not completed until February 11, 2025.
Client #4 was admitted April 4, 2025 and still a current client. The client ' s initial treatment plan was due by May 4, 2025 but not completed until May 12, 2025.
Client #7 was admitted May 9, 2025 and still a current client. The client ' s initial treatment plan was due by June 8, 2025 but not completed until June 13, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director reviewed this deficiency with the clinical supervisor and the CEO on 10/10/25. At this time, it was decided to change program policy from 'initial treatment plan is completed within 30 days,' to 'initial treatment plan will be completed by the fifth session.' This policy change will be effective as of 11/1/2025. This will account for potential missed appointments or changes in scheduled sessions.
All treatment plans will be tracked and monitored by the clinical supervisor to ensure they are done by the fifth session.
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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 a review of client records, the facility failed to complete treatment plan updates at least every 60 days in three of six records reviewed.
Client #3 was admitted January 3, 2025 and still a current client. A treatment plan was completed on May 30, 2025 and an update was due by July 29, 2025 but not completed until July 31, 2025.
Client #4 was admitted April 4, 2025 and still a current client. A treatment plan was completed on July 8, 2025 and an update was due by September 6, 2025 but not completed until September 9, 2025.
Client #5 was admitted March 12, 2025 and still a current client. A treatment plan was completed on April 8, 2025 and an update was due by June 7, 2025 but not completed until June 11, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 25, 2024 licensing inspection.
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Plan of Correction
Treatment plan updates will be tracked by the clinical supervisor on an excel spreadsheet for each clinician. Clinicians will review all treatment plan updates during weekly clinical supervision the week prior to the 60-day due date. At the time of supervision the clinician will complete all treatment plan updates during the one-hour scheduled time immediately following supervision allotted specifically for treatment plan updates. This will be effective beginning 11/1/2025. |