INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 13, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Diakon Child, Family and Community Ministrieswas 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:
|
Plan of Correction
|
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
|
Observations
Based on a review of the clinical supervisor ' s personnel record, the facility failed to document monthly meetings with their supervisors to discuss their duties and performance for the first 6 months employment in that position.
Employee #3 was promoted to a clinical supervisor position on May 23, 2023, and was still in that position at the time of the inspection. There was no documentation available to verify that these meetings had occurred.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
704.6(e)- Employee #3 will receive
weekly documented supervision
beginning 6/21/24 and ending
12/20/24. Frequency of additional
supervision meetings for employee
#3 will be based on clinical
supervisors skill level. Additional
clinical supervisors hired will receive
weekly documented supervision for
the first 6 months and frequency of
additional supervisions will be based
on skill level of the clinical
supervisor. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
|
Observations
Based on a review of the facilities policy and procedure manual and interviews with the facility staff, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
709.23 The Policy & Procedure manual will be reviewed on an
annual basis by the Project Director. A signed statement indicating this
review will be available for inspection. Compliance with this standard will be monitored and
enforced by the Facility Director through staff meetings and supervision. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on a review of facility policies, the facility failed to include of all the required client rights, including the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
The facility's client rights policy " 709.91 (A1) III. (a.) did not include age, creed, sex, color, handicap, or religion.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
709.30 The Project Director will develop written policies and
procedures on client rights which will emphasize the project will not
discriminate in the provision of services on the basis of age, race,
creed, sex, ethnicity, color, national origin, marital status, sexual
orientation, handicap or religion. The policy will be revised and in
compliance by 7/1/24. These rights are reviewed with the client during
the intake session. The client signs the Acknowledgement Form
showing they have been notified of these rights.
|
709.92(a)(3) 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:
(3) Proposed type of support service.
|
Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in three out of three applicable records reviewed.
Client #1 was admitted on December 5, 2023, and was still active at the time of the inspection. The comprehensive treatment plan, completed January 9, 2024, did not document client support services.
Client #3 was admitted on March 19, 2024, and was still active at the time of the inspection. The comprehensive treatment plan completed March 19, 2024 did not document client support services.
Client #4 was admitted on January 9, 2024, and was discharged on March 26, 2024. The comprehensive treatment plan, completed January 23, 2024, did not document client support services.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
709.92. (a)(3)
The Treatment and rehabilitation plan will be revised 7/1/24 by the facility director and additional fields added that include a designated area for documenting proposed types of support services. Monthly monitoring of compliance will be the responsibility of the facility director.
|
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.
|
Observations
Based on a review of client records, the facility failed to document the review of treatment and rehabilitation plans every sixty days in two of three applicable client records.
Client #1 was admitted on December 5, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was documented in the client record January 9, 2024. An updated treatment plan was due no later than March 9, 2024; however, the updated treatment plan was not completed until March 19, 2024.
Client #5 was admitted on May 2, 2022, and discharged on December 14, 2023. A treatment plan update was documented in the client record on September 11, 2023. An updated treatment plan was due no later than November 11, 2023; however, the updated treatment plan was not completed until December 14, 2023.
This is a repeat citation from the June 3, 2022 and June 15, 2023 licensing inspection renewals.
These findings were reviewed with the facility during the inspection process.
|
Plan of Correction
709.92(b)
A treatment plan tracking spreadsheet was developed 6/21/24 that denotes due dates of plans on an ongoing basis. Weekly monitoring of treatment plan due dates will be conducted by each staff member and reviewed weekly during staff meetings. Progress toward compliance of treatment plan completion and monitoring will be reviewed monthly and will be the responsibility of the facility director.
|
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.
|
Observations
Based on a review of outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in two out of three applicable records reviewed.
Client #3 was admitted on March 19, 2024, and was still active at the time of the inspection. The comprehensive treatment plan dated March 19, 2024, indicated one individual session per week. During the period between April 1, 2024, through April 16, 2024, there were no sessions documented in the client record.
Client #5 was admitted on May 2, 2022, and was discharged December 14, 2023. An updated treatment plan dated September 11, 2023, indicated 4-5 individual sessions per month. During the period between November 1, 2024, through November 31, 2024, only two individual sessions were documented in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
709.92 (c) Facility will ensure that treatment services offered are in accordance with recommended session frequency according to the comprehensive treatment plan. Clinical staff will be re-educated on expectations regarding treatment planning at next staff meeting on 7/11/24. The facility director will monitor compliance on a monthly basis. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
|
Observations
Based on a physical plant inspection, the facility failed to conspicuously display the hours of project operation to the general public.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
709.94(b)
The hours of operation are posted conspicuously to the general public as of 6/24/24. The facility director is responsible for monitoring compliance with postings. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
|
Observations
Based on a physical plant inspection, the facility failed to conspicuously display the telephone number to the general public for emergency purposes.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
709.94(c)
A telephone number for emergency services is posted conspicuously to the general public as of 6/24/24. The facility director is responsible for monitoring compliance with postings.
|
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.
|
Observations
Based on the review of patient records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction was submitted to the Department for inspections occurring on June 3, 2022, and June 15, 2023, addressing the requirement that treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. Treatment plan updates was again found to be a deficiency in the June 13, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
709.17(a)(3)
Annual deficiencies and approved plans of correction will be reviewed by Diakon's corporate compliance team by 7/1/24. The facility director will provide quarterly reports to the compliance team that include results from monthly treatment plan compliance monitoring. |