INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 6, 2021 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:
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Plan of Correction
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. A fire extinguisher located in the hallway near the side exit expired September 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Extinguisher in question was inspected as of 7/8/2021.
Provider is a renter in this building. Timeliness of inspections was discussed with landlord. Facility will follow up to ensure regular inspection of all fire extinguishers. |
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 three of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records # 2, #4 and # 6.
Client # 2 was admitted on June 17, 2020 and was still active at the time of the inspection. A correspondence with a hospital on May 10, 2021 provided a statement "no records, client is D&A". There was not a valid informed and voluntary consent from the client for the disclosure of information in the client record.
Client # 4 was admitted on May 24, 2021 and was still active at the time of the inspection. Authorizations to a funding source occurred on May 14, 2021. There was not a valid informed and voluntary consent from the client for the disclosure of information in the client record.
Client # 6 was admitted on September 23, 2020 and discharged on January 13, 2021. Authorizations to a funding source occurred on August 18, 2020 through January 13, 2021 without an informed and voluntary consent from the client for the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 8, 2020 and July 9, 2019 annual licensing inspection.
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Plan of Correction
Staff education was provided on 7/21/2021 regarding consent to release information.
Re-iteration of 42 CFR was presented. Staff were given two articles with exams on Confidentiality and 42 CFR.
Consents to release information have been incorporated as part of the assessment and intake process as to ensure compliance moving forward.
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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 four of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed to not exceed 255.5 (b).
Client # 1 was admitted on April 20, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a funding agency, other agency, dated April 20, 2021 and a probation office dated June 8, 2021 that allowed the release of "other" "treatment and funding information".
Client # 2 was admitted on June 17, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a probation office dated June 19 and 29, 2020 that allowed the release of "other" "treatment and funding information".
Client # 6 was admitted on September 23, 2020 and was discharged on January 13, 2021. An informed and voluntary consent from the client for the disclosure of information to a probation office and other agency dated September 23, 2020 that allowed the release of "any information as seen fit".
Client # 7 was admitted on December 17, 2020 and was discharged on March 16, 2021. An informed and voluntary consent from the client for the disclosure of information to a funding source dated December 17, 2020 that allowed the release of "other" "treatment information".
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff education was provided on 7/21/2021 regarding consent to release information.
Re-iteration of 42 CFR was presented. Staff were given two articles with exams on Confidentiality and 42 CFR.
Consents to release information have been incorporated as part of the assessment and intake process as to ensure compliance moving forward. |
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 five of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include the dated signature of the client. Informed and voluntary consent forms from the client were completed on behalf of the client from staff and only indicated a verbal consent from the client in client records # 1, 2, 6, and 7.
Client # 1 was admitted on April 20, 2021 and was still active at the time of the inspection.
An informed and voluntary consent from the client for the disclosure of information to a funding source, other agency, and probation officer had a dated signature of a witness however, it only contained a verbal telehealth consent by the client.
Client # 2 was admitted on June 17, 2020 and was still active at the time of the inspection.
An informed and voluntary consent from the client for the disclosure of information to a case manager had a dated signature of a witness however, it only contained a verbal telehealth consent by the client.
Client # 4 was admitted on May 24, 2021 and was still active at the time of the inspection.
An informed and voluntary consent from the client for the disclosure of information to a probation officer had a dated signature of a witness however, it only contained a verbal telehealth consent by the client.
Client # 6 was admitted on September 23, 2020 and was discharged on January 13, 2021.
An informed and voluntary consent from the client for the disclosure of information to a case probation officer and other agency had a dated signature of a witness however, it only contained a verbal telehealth consent by the client.
Client # 7 was admitted on December 17, 2020 and was discharged on March 16, 2021.
An informed and voluntary consent from the client for the disclosure of information to a funding source and emergency contact had a dated signature of a witness however, it only contained a verbal telehealth consent by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Whereby telehealth is done 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). When verbal consent is given during a telehealth session the clinical staff person will follow up with a written consent prior to the release of confidential client information. This will be in compliance effective 8/2/2021. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality review 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.
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Observations
Based on two of four applicable client records reviewed, the facility failed to document treatment and rehabilitation plans being reviewed and updated at least every 60 days in client records # 6 and # 7.
Client # 6 was admitted on September 23, 2020 and discharged on January 13, 2021. A treatment plan was completed on September 30, 2020. A treatment plan update was due to occur no later than November 30, 2020 but did not occur until December 11, 2020.
Client # 7 was admitted on December 17, 2020 and discharged on March 16, 2021. A treatment plan was completed on December 30, 2020. A treatment plan update was due to occur no later than March 1, 2021. There was no documentation of another treatment plan update in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical staff will assure treatment and rehabilitation plans shall be reviewed and updated with the client at least every 60 days per Diakon Family Life Service's policy. This will be in compliance effective 8/2/2021. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality review and supervision. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on two of two applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance to the facilities policy and procedure manual. The facility policy and procedure manual indicated follow-up information to occur ninety days after discharge and six months after discharge.
Client # 6 was admitted on September 23, 2020 and discharged on January 13, 2021. A follow-up was due to occur no later than April 13, 2021. There was no documentation of follow-up information in the client record.
Client # 7 was admitted on December 17, 2020 and discharged on March 16, 2021. A follow-up was due to occur no later than June 16, 2021. There was no documentation of follow-up information in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical staff shall assure a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following: (11) Follow-up information. It is the responsibility of the clinical staff person to make an attempt to follow up on a client's status after being discharged from the program. The clinical staff will complete follow up per Diakon Family Life Service's policy. This will be in compliance effective 8/2/2021. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality review and supervision.
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