INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 6, 2025 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 Ministries 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:
|
Plan of Correction
|
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of fire drill logs from June 2024 through April 2025, the facility failed to prepare alternative exit route to be used during fire drills, as all drills utilized the same exit route, the front door.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
705.28d5 The Facility Director will meet with Clinical Directors, clinical staff, and administrative staff to review 705.28b5 and to educate them of Diakon's emergency exits and emergency preparedness plan. The Facility Director will revise fire drill logs to ensure that details of fire drill is accurately documented. This will be in compliance effective 6/1/2025. Compliance with this standard will be enforced and monitored by the Facility Director through monthly fire drill log review and staff training. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on a review of the July, 2024 through April, 2025, fire drill logs the facility failed to set off the fire alarm or smoke detector during each fire drill. The facility used a verbal command for the drill.
The facility does not currently have an exemption waiver in place for this regulatory requirement.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 12, 2024 licensing inspection.
|
Plan of Correction
705.28d7 The Facility Director submitted an exemption waiver request for 705.28d7 on 5/1/2025 for use of verbal command fire drills. During the interim, the Facility Director will ensure that fire drills are conducted by use of a hand-held device/sounding alarm and this will occur by 6/1/2025. |
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 six out of six applicable records reviewed.
Client #1 was admitted on November 11, 2024 and was still active at the time of the inspection. The treatment plan was dated November 11, 2024.
Client #2 was admitted on January 20, 2025 and was still active at the time of the inspection. The treatment plan was dated January 20, 2025.
Client #3 was admitted on February 10, 2025 and was still active at the time of the inspection. The treatment plan was dated February 10, 2025.
Client #4 was admitted on February 19, 2025 and was still active at the time of the inspection. The treatment plan was dated February 19, 2025.
Client #5 was admitted on October 2, 2024 and was discharged on January 22, 2025. The treatment plan was dated October 2, 2024.
Client #7 was admitted on October 21, 2024 and was discharged on January 30, 2025. The treatment plan was dated October 21, 2025.
This is a repeat citation from the June 12, 2024 licensing inpsection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
790.92a3 The Facility Directors will meet with the Clinical Director regarding needed changes to the Treatment Plan document in Carelogic. The Clinical Director will revise the Treatment Plan document in the agency's ECR to include the proposed type of support service. This will be in compliance by 6/16/25. Compliance with this standard will be monitored and enforced by the Facility Directors and Clinical Coordinators through staff training, quality reviews 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.
|
Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven records reviewed.
Client #1 was admitted on November 11, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on November 11, 2024 and an update was due no later than January 11, 2025; however, it was not completed until February 3, 2025.
Client #3 was admitted on February 10, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on February 10, 2025 and an update was due no later than April 12, 2025; however, it was not completed until April 14, 2025.
Client #5 was admitted on October 2, 2024 and was discharged on January 22, 2025. A comprehensive treatment plan was completed on October 2, 2024 and an update was due no later than December 2, 2024; however, it was not completed until December 4, 2024.
Client #6 was admitted on May 6, 2024 and was discharged on March 7, 2025. A treatment plan update was completed on November 4, 2024 and the next update was due no later than January 4, 2025; however, it was not completed until January 6, 2025.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
790.92b The Facility Directors will meet with the clinical staff to review 790.92b and to educate them that Treatment Plans shall be reviewed and updated at least every 60 days. The clinical staff will ensure treatment plans shall be reviewed and updated with the client at least every 60 days per policy. This will be in compliance effective 6/1/2025. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Directors through staff meetings, staff training, quality reviews and supervision. |