INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 6, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Independent Family Services, Inc. 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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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the facility's fire drill log for the months of January 2022 through November 2022, the facility failed to provide documentation of fire drills being conducted on different days of the week, at different times of the day and on different staffing shifts. All fire drills were conducted between the hours of 8 am and 8:30 am.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The IFS Compliance Officer will review on 1/03/23 with all IFS SUD staff members, the IFS Fire Safety policy and procedures (705.28(d)(6), that states, "Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts".
The fire drill log will be reviewed by the Compliance Officer and IFS SUD Program Director before scheduling the next fire drill to ensure the policy is effectually carried out. |
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 unusual incidents, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving the death or serious injury due to trauma, suicide, medication error or unusual circumstances.A death was reported to a funding agency on March 1, 2022 however, it was not reported to the department.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
IFS Agency staff, Compliance Officer & SUD Outpatient Clinical Supervisor, reviewed and updated the IFS Outpatient SUD Policy & Procedure Manual "Unusual Incidents" to include the use of the DDAP Electronic Reporting System for the use in reporting "Unusual Incidents" and to include the procedure to report these types of incidents within 3 business days to the department. Henceforth, all Unusual Incidents are to be reported to DDAP by the IFS Clinical Supervisor or Program Director.
The IFS Clinical Supervisor utilized the DDAP Emergency Reporting System to report the client death on 12/21/22: Event # 884971- which was accepted in the DDAP-Central Office by Irlene Sweets. |
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 two of four applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records # 1 and # 3.Client # 1 was admitted on March 9, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on March 24, 2022. A treatment and rehabilitation plan update was due no later than May 24, 2022 however, a treatment and rehabilitation plan update did not occur until June 1, 2022. A treatment and rehabilitation plan update was due no later than August 1, 2022 however, a treatment and rehabilitation plan update did not occur until September 22, 2022. A treatment and rehabilitation plan update was due no later than November 22, 2022 however, another treatment and rehabilitation plan update did not occur.Client # 3 was admitted on May 31, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on July 8, 2022. A treatment and rehabilitation plan update occurred on August 25, 2022. A treatment plan update was due to occur no later than October 25, 2022 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
The IFS clinical staff believed that the client needed to be present and sign the treatment plan update for it to be completed, thus delaying the treatment plan update process.
The IFS Compliance Officer and Clinical Supervisor will review the IFS SUD Policy & Procedures (709.92(b) "Treatment and rehabilitation plans shall be reviewed and updated every 60 days", for outpatient clients on the scheduled 1/03/23 staff meeting.
The IFS Clinical Supervisor will assist the clinical staff in coordinating all treatment plan updates with the weekly IFS Treatment Team meeting held every Tuesday. The clinical staff will present each treatment team update for their respective clients at the weekly Treatment Team meetings within the 60- day window permitted with or without the client's signature. The compliance team will include upon their monthly record review that the initial Individual Treatment Plan be updated within 60 days and henceforth from that time within every 60 days thereafter. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on four of seven client records reviewed, the facility failed to shall assure that counseling services are provided according to the individual treatment and rehabilitation plan in client records # 1, 2, 3, and 4. Client # 1 was admitted on March 9, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on March 24, 2022 and updated June 1, 2022 and September 22, 2022 indicating individual and group sessions to occur weekly. A review of the client record of service and progress notes indicate the last counseling session occurred on November 11, 2022.Client # 2 was admitted on June 29, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on August 29, 2022. A treatment plan update occurred on October 31, 2022 indicating individual sessions occur weekly. A review of the client record of service and progress notes indicate the last counseling session occurred on October 31, 2022.Client # 3 was admitted on May 31, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on August 25, 2022 indicating individual and group sessions occur weekly. A review of the client record of service and progress notes indicate the last counseling session occurred on September 15, 2022 and the last documentation of contact occurred on November 1, 2022.Client # 4 was admitted on September 12, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on October 13, 2022 indicating individual and group sessions to occur weekly. A review of the client record of service and progress notes indicate the last counseling session occurred on November 17, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The process of submitting the client documentation to be signed by the IFS Clinical Supervisor and Medical Director and then re-entered into the client record needs to be more expeditious to better reflect the current and ongoing client involvement with the agency.
All documents to be signed by the IFS Clinical Supervisor and Medical Director, including, but not limited to treatment plans, treatment plan updates and specified progress notes shall be submitted by the IFS clinical team daily, to the file designated as such in the IFS SUD file room. The Clinical Supervisor shall review and sign the clinical documents bi-weekly and return to the designated file for weekly review and signature by the IFS Medical Director. The returned clinical documents will be returned to each clinician respective of their clients to be entered into the client record within 7 business days.
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on three of seven client records reviewed, the facility failed to provide a complete client record to include a record of service that is reflective of the client ' s progress notes in client records # 1, 5, and 7.Client # 1 was admitted on March 9, 2022 and was still active at the time of the inspection. A review of progress notes indicates an individual session occurred on November 11, 2022 and group sessions occurred on November 3 and 10, 2022 however, there was no documentation for those dates on the client record of service.Client # 5 was admitted on January 21, 2022 and was discharged July 25, 2022. A review of progress notes indicates a session occurred on March 25, 2022 however, there was no documentation for that date on the client record of service.Client # 7 was admitted on June 24, 2022 and was discharged September 8, 2022. A review of progress notes indicates a session occurred on June 24, 2022 however, there was no documentation for that date on the client record of service.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The IFS Compliance Officer reviewed with the IFS SUD staff members the IFS Client Record Policy & Procedures (709.92(a)(3), " There shall be a complete record on an individual which includes information relative to the client's involvement with the project" on the 12/13/22 staff meeting.
The IFS SUD staff will review each active client record to include a "Service Log" that is current and accurately reflects the dates of service for the client by 12/20/22. The IFS Compliance Officer and administrative assistant will review all active client records for 100% compliance for an accurate and up to date "Service Log" by 12/27/22. As well, the compliance team will review each active record monthly and at discharge/termination that the "Service Log" is current and accurate. |