INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 10, 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 Family Life Services 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 July 2023 - May 2024, the facility failed to prepare alternative exit routes to be used during fire drills, as all drills utilized the same exit routes.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Facility staff were trained on the requirement and importance of using alternative exit routes during fire drills. This will be in compliance effective 7/1/24. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinators through staff meetings, staff training and oversight. |
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
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 and procedures, the facility failed to include all of the required client rights, including that 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
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. This 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 outpatient client records, the facility failed to document proposed type of support service on individual treatment plans in seven out of seven applicable records reviewed.
Client #1 was admitted on March 4, 2024, and was still active at the time of the inspection. The comprehensive treatment plan, completed April 16, 2024, did not document client support services.
Client #2 was admitted on April 5, 2024, and was still active at the time of the inspection. The comprehensive treatment plan, completed May 7, 2024, did not document client support services.
Client #3 was admitted on April 18, 2024, and was still active at the time of the inspection. The comprehensive treatment plan, completed May 13, 2024, did not document client support services.
Client #4 was admitted on October 12, 2023, and was discharged on March 13, 2024. The comprehensive treatment plan, completed October 23, 2023, did not document client support services.
Client #5 was admitted on October 3, 2023, and was discharged on May 16, 2024. The comprehensive treatment plan, completed October 10, 2023, did not document client support services.
Client #6 was admitted on October 27, 2023, and was discharged on May 29, 2024. The comprehensive treatment plan, completed December 8, 2023, did not document client support services.
Client #7 was admitted on October 17, 2023, and was discharged on April 16, 2024. The comprehensive treatment plan, competed November 1, 2023, did not document client support services.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Facility 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 7/1/24. Compliance with this standard will be monitored and enforced by the Facility Director 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 client records, the facility failed to update treatment and rehabilitation plans at least every 60 days in two out of five applicable client records.
Client #4 was admitted on October 12, 2023, and was discharged on March 13, 2024. A comprehensive treatment plan was completed on October 23, 2023, an updated treatment plan was due no later than December 23, 2023; however, a treatment plan was not completed until January 22, 2024.
Client #6 was admitted on October 27, 2023, and was discharged on May 29, 2024. A comprehensive treatment plan was completed on December 8, 2023, an updated treatment plan was due no later than February 8, 2024; however, a treatment plan was not completed until February 14, 2024.
This is a repeat citation from the June 3, 2023 licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
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 Services policy. This will be in compliance effective 7/1/24. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinators through staff meetings, staff training, quality reviews and supervision. |