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 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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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on three of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated signature of the client but instead had "verbal" in the client signature line.
Client # 3 was admitted on February 25, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated February 25, 2022 to a funding agency did not have a valid signature by the client but instead had "verbal" in the signature line. Client signed informed and voluntary consent form on March 4, 2022. Authorization for funding occurred on February 25, 2022.
Client # 4 was admitted on February 17, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated February 17, 2022 to a primary care physician did not have a valid signature by the client but instead had "verbal" in the signature line.
Client # 7 was admitted on August 3, 2021 and was discharged April 4, 2022. An informed and voluntary consent from the client for the disclosure of information dated August 19, 2021 to a funding source did not have a valid signature by the client but instead had "verbal telehealth phone" in the signature line.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 9, 2021 annual licensing inspection.
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Plan of Correction
Whereby telehealth is done the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. This will be done by scheduling the client in person for the initial session when releases are secured. The consent must be in writing and include, but not be limited to: (4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients). When verbal consent is given during a telehealth session the clinical staff person will follow up with a written consent prior to the release of confidential client information. This will be in compliance effective 6/20/2022. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality review 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 three of five applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records # 5, 6 and # 7.
Client # 5 was admitted on November 18, 2021 and was discharged on April 26, 2022. A treatment and rehabilitation plan was developed on November 18, 2021. A treatment and rehabilitation plan update was due no later than January 18, 2022 however, a treatment and rehabilitation plan update did not occur until February 3, 2022.
Client # 6 was admitted on December 7, 2021 and was discharged on February 23, 2022. A treatment and rehabilitation plan was developed on December 7, 2021. A treatment and rehabilitation plan update was due no later than February 7, 2022 however, there was no documentation of a treatment plan update in the client record.
Client # 7 was admitted on August 3, 2021 and was discharged on April 4, 2022. A treatment and rehabilitation plan was developed on November 22, 2021. A treatment and rehabilitation plan update was due no later than January 22, 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.
This is a repeat citation from the July 9, 2021 annual licensing inspection.
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Plan of Correction
The clinical staff will assure treatment and rehabilitation plans shall be reviewed and updated with the client at least every 60 days per Diakon Family Life Service's policy. This will be in compliance effective 6/20/2022. 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. |
709.92(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 assure that counseling services are provided according to the individual treatment and rehabilitation plan in client records #2, 4, 6, and 7.
Client # 2 was admitted on March 28, 2021 and was still active at the time of the inspection. A treatment plan developed on April 18, 2022 indicated 3-5 individual sessions weekly. A review of progress notes and record of service document an individual session on April 18, 2022 however, no other individual sessions were documented in the client record.
Client # 4 was admitted on February 17, 2022 and was still active at the time of the inspection. A treatment plan developed on February 17 and April 7, 2022 indicated 1-2 family sessions weekly. A review of progress notes and record of service fails to document a family session to have occurred.
Client # 6 was admitted on December 7, 2021 and was discharged February 23, 2022. A treatment plan developed on December 7, 2021 indicated 1-2 individual sessions weekly. A review of progress notes and record of service document an individual session on January 10, 2022 however, no other individual sessions were documented in the client record.
Client # 7 was admitted on August 32021 and was discharged April 4, 2022. A treatment plan developed on August 11, 2021 indicated 3-7 family and couple sessions weekly. A review of progress notes and record of service fails to document family/couple sessions to have occurred. Also, a treatment plan developed on September 27, 2021 indicated 3-4 individual sessions weekly however, there were not at least 3 individual sessions weekly documented in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 9, 2021 annual licensing inspection.
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Plan of Correction
The clinical staff shall assure that counseling services are provided according to the individual treatment and rehabilitation plan. The clinical staff will follow treatment plan recommendations regarding frequency and type of treatment. This will be in compliance effective 6/20/2022. 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)(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 facilities policy and procedure manual. The facility policy and procedure manual indicated follow-up information to occur sixty days after discharge by letter.
Client # 6 was admitted on December 7, 2021 and was discharged on February 23, 2022. A follow-up was due to occur no later than April 23, 2022. There was no documentation of follow-up information in the client record.
Client # 7 was admitted on August 3, 2021 and was discharged on April 4, 2022. A follow-up was due to occur no later than May 4, 2022. There was no documentation of follow-up information in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 9, 2021 annual licensing inspection.
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Plan of Correction
The clinical staff shall assure 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. It is the responsibility of the clinical staff person to make an attempt to follow up on a client's status after being discharged from the program. The clinical staff will complete follow up per Diakon Family Life Service's policy and a copy of the letter will be placed in the client record when completed. This will be in compliance effective 6/20/2022. 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. |