INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 16, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Community Service Foundation, 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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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 a review of personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of three applicable personnel records reviewed.
Employee # 4 was hired as a counselor on October 25, 2023 and was due to have the HIV/AIDS training and the TB/STD training no later than October 25, 2024. Both the HIV/AIDS and TB/STD trainings were not completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of three applicable personnel records reviewed. Clinical Supervisor will ensure all staff persons receive the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe. This will be done through training of Human Resources staff and regular personnel records checks. Employee #4 completed the TB/STD training on June 7, 2024 but due to technical difficulties the certificate was not released until recently. Employee #4 will complete the HIV/AIDS training by 3/31/2025. The facility will be compliant by 3/31/2025. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's January 2024 through October 2024 fire drill logs, the facility failed to ensure that unannounced fire drills were conducted at least once a month. There were no fire drills completed and documented during the months of July 2024 and August 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure that unannounced fire drills were conducted at least once a month. There were no fire drills completed and documented during the months of July 2024 and August 2024. The Clinical Supervisor will ensure unannounced fire drills are conducted monthly and documented. This will be done through training of staff and monthly reviews of the fire drill logs. The facility will be compliant by 2/28/2025. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, a preliminary treatment and rehabilitation plan in one of one applicable client record reviewed.
Client # 1 was admitted on April 3, 2024 and was still active at the time of the inspection. There was no preliminary treatment plan documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document, as part of their intake and admission process, a preliminary treatment and rehabilitation plan in one of one applicable client record reviewed. Clinical Supervisor will ensure that a preliminary treatment and rehabilitation plan is documented in the client record as part of the intake and admission process. This will be done through training of staff and regular client file checks. The facility will be compliant by 2/28/2025. |
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 ensure individual treatment and rehabilitation plans were developed with the client in five of five applicable client records reviewed.
Client # 1 was admitted on April 3, 2024 and was still active at the time of the inspection. The individual treatment plan was completed by facility staff on April 30, 2024; however, there was no documentation in the record indicating the plan was developed with the client.
Client # 2 was admitted on June 4, 2024 and was still active at the time of the inspection. The individual treatment plan was completed by facility staff on June 7, 2024; however, there was no documentation in the record indicating the plan was developed with the client.
Client # 3 was admitted on July 30, 2024 and was still active at the time of the inspection. The individual treatment plan was completed by facility staff on August 1, 2024; however, there was no documentation in the record indicating the plan was developed with the client.
Client # 4 was admitted on March 19, 2024 and was discharged on September 18, 2024. The individual treatment plan was completed by facility staff on March 20, 2024; however, there was no documentation in the record indicating the plan was developed with the client.
Client # 5 was admitted on August 19, 2024 and was discharged on October 4, 2024. The individual treatment plan was completed by facility staff on August 22, 2024; however, there was no documentation in the record indicating the plan was developed with the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure individual treatment and rehabilitation plans were developed with the client in five of five applicable client records reviewed. The clinical supervisor will ensure the electronic client record is updated to reflect that individual treatment and rehabilitation plans are developed with the client and is documented in the care plan and/or clinical note. This will be implemented by regular file checks and training of staff. Facility will be compliant by March 31, 2025. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five of five client records reviewed.
Client # 1 was admitted on April 3, 2024 and was still active at the time of the inspection. The individual treatment plan was completed by facility staff on April 30, 2024 and did not include documentation of the type and frequency of treatment services to be provided to the client.
Client # 2 was admitted on June 4, 2024 and was still active at the time of the inspection. The individual treatment plan, completed by facility staff on June 7, 2024 and did not include documentation of the type and frequency of treatment services to be provided to the client.
Client # 3 was admitted on July 30, 2024 and was still active at the time of the inspection. The individual treatment plan, completed by facility staff on August 1, 2024 and did not include documentation of the type and frequency of treatment services to be provided to the client.
Client # 4 was admitted on March 19, 2024 and was discharged on September 18, 2024. The individual treatment plan, completed by facility staff on March 20, 2024 and did not include documentation of the type and frequency of treatment services to be provided to the client.
Client # 5 was admitted on August 19, 2024 and was discharged on October 4, 2024. The individual treatment plan, completed by facility staff on August 22, 2024 and did not include documentation of the type and frequency of treatment services to be provided to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five of five client records reviewed. The clinical supervisor will ensure the electronic client record is updated to reflect the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan and is documented in the care plan. This will be implemented by regular file checks and training of staff. Facility will be compliant by March 31, 2025. |
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 treatment and rehabilitation plans were reviewed and updated at least every sixty days in four of six applicable client records reviewed.
Client # 1 was admitted on April 3, 2024 and was still active at the time of the inspection. The individual treatment plan was completed on April 30, 2024 and the first update was due no later than June 30, 2024; however, the update was not completed at the time of the inspection.
Client # 2 was admitted on June 4, 2024 and was still active at the time of the inspection. The individual treatment plan was completed on June 7, 2024 and the first update was due no later than August 7, 2024; however, the update was not completed at the time of the inspection.
Client # 3 was admitted on July 30, 2024 and was still active at the time of the inspection. A treatment plan update was completed on September 30, 2024 and the next update was due no later than November 30, 2024; however, there was no update completed prior to discharge.
Client # 4 was admitted on March 19, 2024 and was discharged on September 18, 2024. The individual treatment plan was completed on March 20, 2024 and the first update was due no later than May 20, 2024; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in four of six applicable client records reviewed. The Clinical Supervisor will ensure the electronic client record includes a clinical note that the treatment and rehabilitation plan was reviewed and is updated every 60 days. This will be done through training of staff and regular client file checks. The facility will be compliant by 3/31/2025 |