INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 12, 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 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
Based on the review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics within the regulatory timeframes in one of twelve personnel records reviewed.
Employee #8 was hired as a counselor on August 16, 2021 and was due to receive the minimum of 6 hours of HIV/AIDS training and 4 hours of TB/STD training no later than August 16, 2022. The employee completed the HIV/AIDS training within the regulatory timeframe; however, there was no documentation of the completion of the TB/STD training as of the date of the inspection.
This is a repeat citation from the December 16, 2021 annual licensing renewal inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #8 has registered for TB/STD/HEP training scheduled for January 24, 2023.
HR will continue to monitor personnel files to ensure all staff are up-to-date on their required DDAP trainings. |
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
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors during the facility ' s July 2021 through June 2022 training year in one of six applicable personnel records reviewed.
Employee #5 was hired as a counselor on February 23, 2015. The personnel record documented 18 hours of annual training during the reviewed training year.
This is a repeat citation from the December 16. 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
HR will continue to monitor personnel files to ensure all staff are up-to-date on required trainings.
Supervisor will check-in with Employee #5 and team on a quarterly basis to ensure he is up-to-date on required annual trainings. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirement Facility Summary Report, the facility failed to ensure that the Full Time Equivalent (FTE) counselor caseload for counseling in outpatient programs did not exceed 35 active clients in three of eleven counselors employed.
The counselor FTE is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee #4 was hired as a counselor on July 11, 2011 and was still employed at the time of the inspection. The ratio calculation was as follows: 1/37.50= .0266(FTE); 1/.0266= 37.59 which equals a client/counselor ratio of 37:1.
Employee #7 was hired as a counselor on January 6, 2020 and was still employed at the time of the inspection. The ratio calculation was as follows: 2/37.50= .0533; 2/.0533= 37.52 which equals a client/counselor ratio of 37:1
Employee #10 was hired as a counselor on January 21, 2020 and was still employed at the time of inspection. The ratio calculation was as follows: 3/37.50= .08; 3/.08= 37.50 which equals a client/counselor ratio of 37:1.
This is a repeat citation from the November 19, 2020 and December 16. 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Family Service makes every attempt to adhere to the DDAP prescribed client ratio for OP LOC, 35:1. While no clinician has over 35 DDAP clients, we need to adhere to a ratio rather than numbers and will make this change when assigning clients to clinician caseloads.
Clinical Supervisor will work with staff to see if there are clients that may be ready for discharge and complete by 1/31/2023.
Clinical Supervisor and HR have actively begun recruiting for additional D&A clinicians. A job posting for D&A Clinicians has been uploaded to Indeed. It is the hope of Family Service to identify, hire, and onboard the appropriate candidates by 2/28/2023. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of nine client records reviewed.
Client #2 was admitted on March 14, 2022 and was active at the time of inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In March 2022, a new Intake Coordinator started in the position. This individual was in training and the missing consent form was not signed as intake coordinator was not aware that it was needed.
For Client #2, documentation of disclosure to the funding source was missing, but has been reviewed with client, who signed on 12/16/2022. Issue was corrected.
Moving forward, Intake Coordinator was made aware of the importance of gathering consent forms during the intake process and will work to ensure all intake forms will be completed in person with live signatures prior to the commencement of treatment.
Clinical Supervisor will continue to remind staff during supervision to ensure consent forms are accurate and updated. |
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 a review of client records, the facility failed to document the dated signature of the client on release of information forms in three of nine client records reviewed.
Client #2 was admitted on March 14, 2022 and was active at the time of inspection. There were release of information forms to an emergency contact and probation and parole that were signed and dated by the witness on March 14, 2021; however, neither form included the dated signature of the client. Additionally, a release of information form to probation and parole was signed and dated by the witness on April 7, 2022; however, the form did not include the dated signature of the client.
Client #3 was admitted on February 17, 2022 and was active at the time of inspection. There was a release of information form to the funding source that was signed and dated by the witness on May 3, 2022; however, the form did not include the dated signature of the client.
Client #8 was admitted on February 24, 2022 and was discharged on December 9, 2022. There were release of information forms to an emergency contact and a funding source that were signed and dated by the witness on February 24, 2022; however, neither form included the dated signature of the client. Additionally, a release of information form to probation and parole was signed and dated by the witness on March 31, 2022; however, the form did not include the dated signature of the client.
This is a repeat citation from the November 19, 2020 and December 16, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #2, client signature appeared blank at first glance. However, Release for Probation/Parole was indeed imbedded within the chart (can provide supporting documentation upon request).
Client #3 is coming to an in-person appointment on January 11, 2023 to sign all documents live. Funding Source ROI will be signed in person on 1/11/2023.
Client #8 was discharged on 12/9/2022, prior to site visit.
Moving forward, Clinical Supervisor will continue to work with team to ensure all intakes will be completed in person to gather live signatures. This will also include the use of quarterly peer reviews. |
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 ensure that all treatment and rehabilitation plans were reviewed and updated at least every sixty days in five of six applicable client records reviewed.
Client #1 was admitted on February 4, 2022 and was active at the time of inspection. A treatment plan update was completed on April 15, 2022, and the next update was due no later than June 15, 2022; however, the update was completed on June 23, 2022. Additionally, the next update was due no later than August 23, 2022; however, the update was completed on September 15, 2022.
Client #2 was admitted on March 14, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on March 14, 2022, and the first update was due no later than May 14, 2022; however, the update was completed on June 27, 2022.
Client #7 was admitted on April 27, 2022 and was discharged on November 25, 2022. The comprehensive treatment plan was completed on May 16, 2022, and the first update was due no later than July 16, 2022; however, the update was completed on September 27, 2022.
Client #8 was admitted on February 24, 2022 and was discharged on December 9, 2022. The comprehensive treatment plan was completed on March 31, 2022, and the first update was due no later than May 31, 2022; however, there were no treatment plan updates completed prior to discharge.
Client #9 was admitted on May 23, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on June 22, 2022, and the first update was due no later than August 22, 2022; however, the update was completed on August 31, 2022. Additionally, the next update was due no later than October 31, 2022; however, the update was completed on November 4, 2022.
This is a repeat citation from the January 10, 2020, November 19, 2020, and December 16, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff were under the impression that Treatment Plan updates were to be completed with client and client's feedback. Scheduling in-person appointments were not always possible due to cancellations and no shows, thus, resulted in late treatment plan updates. Family Service was made aware at the site visit that Treatment Plan updates could be completed by the clinician alone. Clinical supervisor addressed Treatment Planning and Updates with team during supervision on 12/15/2022. Clinical Supervisor and Director of Behavioral Health had scheduled a Treatment Planning and Clinical Documentation training as part of Family Service's Staff Development Plan. The training is scheduled for March 2023. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for obtaining the dated signature of the client on a release of information form was submitted and approved by the Department for the November 19, 2020 and December 16, 2021 annual licensing inspections. Not obtaining the dated signature of the client on a release of information form was again found to be a deficiency in the December 12, 2022, licensing inspection.
A plan of correction for completing treatment plan updates within the regulatory timeframe was submitted and approved by the Department for the January 10, 2020, November 19, 2020 and December 16, 2021 annual licensing inspections. Not completing treatment plan updates within the regulatory timeframe was again found to be a deficiency in the December 12, 2022, licensing inspection.
A plan of correction for a counselor ' s outpatient caseload exceeding 35 active clients was submitted and approved by the Department for the November 19, 2020 and December 16, 2021 annual licensing inspections. Exceeding 35 active clients on a counselor ' s outpatient caseload was again found to be a deficiency in the December 12, 2022, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward, Intake Coordinators will ensure all intake forms are completed in person with live signatures.
Clinical supervisor addressed Treatment Planning and Updates with team during supervision on 12/15/2022. Prior to the site visit, as part of our Staff Development Plan, Clinical Supervisor and Director of Behavioral Health had a Treatment Planning and Clinical Documentation training scheduled for March 2023.
Clinical Supervisor and HR are actively recruiting for additional D&A clinicians to offer more hours dedicated to D&A clients and to ensure proper clinician/client ratio. A job posting was uploaded to Indeed. It is the plan of Family Service to identify, hire, and onboard a new D&A clinician by 2/28/2023. |