INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 28, 2022 through November 29, 2022, 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 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to maintain documentation that counselor assistants receive direct observation of the provision of counseling services as part of their close supervision, in two of two applicable records reviewed.
Employee # 5 was hired as a Bachelor's level counselor assistant by the facility on June 27, 2022. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the weekly close supervision.
Employee # 6 was hired as a Bachelor's level counselor assistant by the facility on June 13, 2022. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the weekly close supervision.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Drug & Alcohol Program Director and Clinical Supervisor met on Monday, December 12, 2022, and discussed the policy and deficiency. Program director and clinical supervisor determined that the clinical supervision notes will be altered to include a review of direct observations. In discussion the clinical supervisor identified that they will continue following policy 704.9 C with the addition of direct observation notes. This change will be effective immediately on 12/19/2022. |
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 a review of fire drill logs from November 2021 through October 2022, the facility failed conduct fire drills at different times of the day and night and on different staffing shifts. Each of the twelve drills occurred at between 8:37 a.m. and 8:45 a.m.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On Tuesday, December 13, 2022, Drug & Alcohol Facility Director discussed with Human Resource Officer and Fiscal and Admin officer who conduct the Fire Drills for the Oil City office. Policy 705.28(d)(6) was reviewed and discussed. As per policy, Facility Director informed them of the need of fire drills in particular need to be completed on different days of the week, at different times of the day and on different shifts and all other requirements of this policy. This is to be documented along with all other pertinent info as dictated in the Fire Safety policy. The Facility Director will review the completed fire drill forms on a random basis to assure of compliance. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment and rehabilitation services, pertaining to case consultations occurring at day 90 and every 60 days thereafter, for three of seven client records reviewed.
Client #4 was admitted on June 22, 2022 and discharged on September 27, 2022. There was no documentation that a case consultation occurred by September 22, 2022.
Client #5 was admitted on November 22, 2021 and was discharged on October 17, 2022. A case consultation was completed on February 23, 2022 and the next one was due to be completed by April 23, 2022; however, the next case consultation did not occur until July 7, 2022.
Client #7 was admitted on January 27, 2022 and was active at the time of the inspection. A case consultation was completed on August 15, 2022 and the next one was due to be completed by October 15, 2022; however, no additional case consultations were completed prior to the date of the inspection.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Program director and clinical supervisor met on December 12, 2022, to review policies on case consults, peer review of charts, and the deficiencies. It was decided that clinical supervisor will address the concerns of not following policy with individual staff and as a program will be address on January 9, 2023, during a clinical staff meeting. Program director and clinical supervisor will ensure completion of case consults in a timely manner during clinical supervision as well. Moving forward, beginning on January 3, 2023, counselors will utilize electronic charting, which will internally track when things are due. Clinical supervisor will implement weekly reports to identify during individual supervision when case consults are needed. |
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
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the specific information to be disclosed in one record reviewed.
Client #2 was admitted on November 23, 2021 and was discharged on April 13, 2022. The record contained a consent to release information form to a funding source signed by the client on November 23, 2021 that was missing the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Drug and Alcohol clinical supervisor will meet with Client #2's primary counselor and discuss the citation within the next week during clinical supervision. Clinical supervisor and Program Director will address confidentiality, informed consent, and releases during the drug and alcohol program meeting on January 9, 2023. Clinical supervisor will conduct randomized chart checks to monitor status of compliance. Counselors will also implement weekly chart checks on peers to reduce possibility of oversight. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of facility policy and procedures and a discussion with facility staff, the facility failed to have a follow-up policy which included follow-up services for clients discharged in a type other than successful.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program director and clinical supervisor met to discuss the policy on follow ups on December 12, 2022. At this time both parties agreed to implement policy to ensure follow up with all individuals who were released from treatment, with the exception of incarcerated or deceased individuals. The policy will remain the same for compliant discharges. In addition, a new policy will be implemented to follow up all terminated clients two weeks after termination. All follow ups will be conducted by the clerk typist at each location by telephone. Each follow up will be logged in the agency's discharge data base.
This policy will be implemented following the January 9, 2023, drug and alcohol staff meeting to ensure time to change the written policy, disseminate the new policy to clerk typists, the human resource manager, and the individual counselors. |