INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 29, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, FamilyLinks, 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(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of administrative information and the facility ' s policy and procedure, the facility failed to include, in their staff development program policy and procedures, the specific timeframes for completion and who is responsible for the completion of the assessment of staff training needs. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Comprehensive staff development policy has been created to include specific timeframes and who is responsible. Staff development policy includes quarterly evaluation of training plans and training needs. Staff will complete an individualized training plan at hire, 1 year after hire and then every calendar year. Individual staff training plans have been updated to include timeframes and most recent required training courses. Training feedback form developed to be completed by staff after every training. All staff will be trained on these new documents at next Outpatient Substance Use meeting on 6/22/22 by Program Manager. |
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.
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Observations
Based on the review of the facility's fire drill log for the months of March 2021 through March 2022, the facility failed to prepare alternate exit routes to be used during fire drills. No exit routes were documented on the April, May, and June 2021 fire logs.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Exits will be included on all fire drill logs including alternative exits. Program Manager is responsible for completing and monitoring each fire drill log to ensure completion of Plan of Correction. |
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.
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Observations
Based on the review of the facility's fire drill log for the months of March 2021 through March 2022, the facility failed to set off a fire alarm or smoke detector during each fire drill. Fire alarms and smoke detectors were not activated for April, May, August, September, October, November, and December 2021, and February and March 2022. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Operating Officer to submit waiver as Familylinks no longer owns the Banksville building and is unable to actually set off the fire alarms. Fire drills continue to be conducted by loudly announcing "Fire Alarm" in lieu of actual alarm sounding. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative information, the facility failed to document a 2020-2021 annual report. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Manager will provide 2020-2021 annual report upon completion in June to meet compliance standard.
Due to the preparation schedule of annual report, waivers will be submitted in advance for 2021-2022 annual report to maintain compliance by COO.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative information, the facility failed to document an annual financial audit for fiscal year 2020-2021.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility will provide 2020-2021 financial audit report upon completion in June to meet compliance standard.
Due to the preparation schedule of financial audits, it will take two cycle years to fully be on schedule per state requirement. Waivers will be submitted in advance for 2022-2023 and 2023-2024 financial audits to maintain compliance while the audit cycle is adjusted. The facility will work with Finance Department to obtain annual financial audit for all future audits.
Responsible Person: Director, COO
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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 a review of client records, the facility failed to document the specific information to be disclosed on the consent to release information forms in two of four applicable records reviewed. Client # 1 was admitted on February 16, 2022 and was active at the time of the inspection . A release of information for an emergency contact was signed by the client on February 10, 2022 but did not include the specific information to be disclosed. Client # 5 was admitted on December 13, 2021 and was active at the time of the inspection. A release of information form to a family member was signed by the client on December 10, 2021 but did not include the specific information to be disclosed. " Other " was indicated, but was blank. A release of information to another agency was signed by the client on December 10, 2021 and did not include the specific information to be disclosed.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Staff retraining on Releases of Information was completed on 5/24/22 to specify the information disclosed. Compliance department to attend staffing meeting on 6/22/22 for further training and deployment of revised Release of Information. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure all current and future clients will be compliant. |
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 two of four applicable records reviewed. Client # 2 was admitted on February 28, 2022 and was active at the time of the inspection. Three release of information forms for a primary care physician and two separate hospitals were signed by the client but did not include the date of the client ' s signature. Client # 3 was admitted on February 28, 2022 and was active at the time of the inspection. A release of information form to a government agency was signed by the client but did not include the date of the client ' s signature. These findings were reviewed with the facility staff during the licensing process. This is a repeat citation from the March 26, 2021 annual licensing inspection.
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Plan of Correction
Staff retraining on Releases of Information was completed on 5/24/22 to specify necessity of client signatures and dates on valid Releases of Information. Compliance department to attend staffing meeting on 6/22/22 for further training and deployment of revised Release of Information. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure all current and future clients will be compliant. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of the witness on release of information forms in four of four applicable records reviewed. Client # 1 was admitted on February 16, 2022 and was active at the time of the inspection . A release of information for an emergency contact was signed by the client on February 10, 2022 but did not include the dated signature of the witness. Client # 2 was admitted on February 28, 2022 and was active at the time of the inspection. Three release of information forms for a primary care physician and two separate hospitals were signed by the client but did not include the date of the client ' s signature or the dated signature of the witness. Client # 3 was admitted on February 28, 2022 and was active at the time of the inspection. A release of information form to a government agency was signed by the client but did not include the date of the client ' s signature or the dated signature of the witness. Client # 5 was admitted on December 13, 2021 and was active at the time of the inspection. A release of information form to a family member was signed by the client on December 10, 2021 but did not include the dated signature of the witness. A release of information to another agency was signed by the client on December 10, 2021 and did not include the dated signature of the witness. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Staff retraining on Releases of Information was completed on 5/24/22 to specify necessity of witness signatures and dates on valid Releases of Information. Compliance department to attend staffing meeting on 6/22/22 for further training and deployment of revised Release of Information. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure all current and future clients will be compliant. |
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.
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Observations
Based on a review of the policy and procedure manual and client records, the facility failed to include documentation of all the required client rights in the policy and in five of five client records reviewed.The policy did not include ethnicity and marital status in the discrimination statement and failed to document that on the written acknowledgment in record # ' s 1, 2, 3, 4, and 5. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client rights document has been updated in accordance with 709.30 (2) to include no discrimination based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. Client right will be signed by all clients at intake and on an annual basis. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure completion. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to provide documentation of written acknowledgment by the client that the client had been made aware of their rights to inspect their own records, that the facility or clinical director may temporarily remove records if determined to be detrimental if presented to the client, and the reasons for removal of information shall be documented in the record in five of five records.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client rights document has been updated in accordance with 709.30 (3) to include client's right to inspect their records and potential removal of portions. Client right will be signed by all clients at intake and on an annual basis. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure completion. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to provide documentation of written acknowledgment by the client that the client had been made aware of their rights to appeal a decision limiting access to their records in five of five records. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client rights document has been updated in accordance with 709.30 (4) to include a client's right to appeal a decision limiting their access to their records. Client right will be signed by all clients at intake and on an annual basis. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure completion. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to provide documentation of written acknowledgment by the client that the client had been made aware of their rights to request the correction of inaccurate, irrelevant, outdated or incomplete information in the record in five of five records.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client rights document has been updated in accordance with 709.30 (5) to include client's rights to request corrections. Client right will be signed by all clients at intake and on an annual basis. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers ensure completion. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to provide documentation of written acknowledgment by the client that the client had been made aware of their rights to submit rebuttal data or memoranda to their own records in five of five records.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client rights document has been updated in accordance with 709.30 (6) to include client's rights to submit a rebuttal. Client right will be signed by all clients at intake and on an annual basis. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to ensure completion. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to provide documentation of disclosure to the client of criteria for admission, treatment, completion, and discharge in four of five records.Client # 1 was admitted on February 16, 2022 and was active at the time of the inspection . Client # 2 was admitted on February 28, 2022 and was active at the time of the Client # 3 was admitted on February 28, 2022 and was active at the time of the inspection. Client # 4 was admitted on March 29, 2022 and was active at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Current Client handbook is in compliance with 709.91 (b) but was not documented in all client charts. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to monitor completion at intake and annually and to ensure all current and future clients will be compliant. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to provide client orientation to the project to include familiarization with project policies in four of five records.Client # 1 was admitted on February 16, 2022 and was active at the time of the inspection. Client # 2 was admitted on February 28, 2022 and was active at the time of the Client # 3 was admitted on February 28, 2022 and was active at the time of the inspection. Client # 4 was admitted on March 29, 2022 and was active at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Current Client handbook is in compliance with 709.91 (b) but client acknowledgement was not documented in all client charts. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to monitor completion at intake and annually to ensure compliance of all current and future charts. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to provide client orientation to the project to include familiarization with services provided in four of five records.Client # 1 was admitted on February 16, 2022 and was active at the time of the inspection. Client # 2 was admitted on February 28, 2022 and was active at the time of the Client # 3 was admitted on February 28, 2022 and was active at the time of the inspection. Client # 4 was admitted on March 29, 2022 and was active at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Current Client handbook is in compliance with 709.91 (b) but client acknowledgement was not documented in all client charts. Chart reviews will be completed in accordance with Behavioral Health Department Compliance Policy at least twice annually by Program Managers to monitor completion at intake and annually of all current and future clients. |