INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Family Service & Children ' s Aid Society 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director and/or facility director met the qualifications for their position in one record reviewed.
Staff #2 was promoted to facility director on April 3, 2023, and did not have the required experience prior to the promotion.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director and Facility Director will review regulations and compare to Facility Director's previous experience and qualifications and receive clarification from DDAP staff regarding terminology.-started 12/1, completed 12/4
Project Director will submit additional information regarding Facility Director's experience which demonstrates compliance with regulatory requirements by 12/8/23.
In the event there is a change in the Facility Director the following will be implemented:
Document how the candidate meets the personnel requirements in the areas of supervision, program planning (utilizing definition provided by DDAP staff), and direct service. This will be completed by Project Director and Human Resources Director-this document will be created for the current Facility Director and submitted to DDAP by 12/12/23. It will be updated as needed if there is a change in the Facility Director position.
The document of qualifications will be kept in the personnel file for the Facility Director-completed by 12/12/23 and updated as needed if there is a change in the Facility Director position.
Project Director and Human Resources Director will review current Facility Director job description to ensure regulatory requirements are included. If not, the job description will be updated with the information by 12/15/23
Project Director will send copy of current Facility Director job description to DDAP by 12/15/23. |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to ensure a mechanism was used to collect feedback on completed training during the 2022-2023 training year in two of three applicable records.
Staff #2 was hired on September 28, 2015 and still a current employee. No feedback forms were submitted for the 2022- 2023 trainings completed.
Staff #4 was hired on March 1, 2011 and still a current employee. No feedback forms were submitted for the 2022-2023 trainings completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Clinical Supervisor met on November 15 to discuss the deficiencies related to staff submitting evaluations for trainings. After reviewing the policy it was determined that does not need to be changes in the policy. Clinical Supervisor also reviewed the policy with the identified staff members number 2 and 4 at this location to ensure that they submit evaluations with all trainings completed. Clinical Supervisor and Program Director will also review the policy with all staff at the next staff meeting on December 15, 2023. All staff will be informed that evaluation forms will need to be completed for all trainings and submitted to the Program Director for their training files.
Program Director will maintain a spreadsheet of submitted trainings and evaluations attached to monitor that each staff submits the evaluation with the certificate of completion. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to complete a written training plan for each employee annually in one of five records reviewed.
Staff #1 has been employed since January 22, 2008 and still a current employee. Staff #1 had no individual training plan for the 2023-2024 training year at the time of onsite inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Executive Director met to discuss deficiencies related to this policy. Executive Director acknowledged not completing a training plan and it was determined that no change in policy needs to occur at this time. Executive Director has also indicated stepping down as the Project Manager and is currently taking the appropriate steps for this. The incoming Project Manager has reviewed the policies on training on November 9 and has an active training plan for the 23'-24' fiscal year.
Project Manager and Program Director will review training plans during annual evaluations to ensure training plans are maintained according to policy. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director and/or facility director completed at least 12 clock hours of training annually in one of two applicable records reviewed.
Staff #1 has been employed since January 22, 2008 and still a current employee. Staff #1 completed no training hours during the facilities 2022-2023 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director met with the Executive Director regarding the deficiency in training hours for the project director. The Executive Director identified stepping down as the Project Director and on November 9 reviewed the training expectations with the incoming Project Director. No changes in policies were deemed necessary as the incoming Project Director reviewed and confirmed expectations for training.
Incoming Project Director will adhere to all required training requirements and complete a minimum of 12 hours annually moving forward. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of training annually in one of one applicable records reviewed.
Staff #4 was hired on March 1, 2011 and still a current employee. Staff #4 only completed 17 training hours during 2022-2023 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director met with the Executive Director on November 9 and discussed required training needs. The policy and requirements were reviewed and deemed adequate. Program Director will review will all staff the training requirements and monitor training hours on a monthly basis with all clinical staff. The identified staff with the deficiency will meet with Program Director upon their return from medical leave to review training expectations and policy. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in one of one applicable records reviewed.
Staff #5 was hired on October 17, 2022 and still a current employee has not been trained on the use of fire extinguishers as of the date of onsite inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director met with the Human Resource Manager, Executive Director, and Clinical Supervisor to review policy deficiencies in this area. On November 9, 2023 the Human Resource Manager and Program Director collaborated to create a training curriculum on fire safety, fire extinguisher use, and emergency planning. This training will be reviewed with all staff members during January 2024 staff meeting and will be implemented as part of the onboarding training for all new staff. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one of one applicable records reviewed.
Staff #5 hired on October 17, 2022 and still a current employee has not been trained to perform assigned tasks during emergencies as of the date of onsite inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director met with the Human Resource Manager, Executive Director, and Clinical Supervisor to review policy deficiencies in this area. On November 9, 2023 the Human Resource Manager and Program Director collaborated to create a training curriculum on fire safety, fire extinguisher use, and emergency planning. This training will be reviewed with all staff members during January 2024 staff meeting and will be implemented as part of the onboarding training for all new staff. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs, the facility failed to maintain a written fire drill record to include problems encountered.
Reviewed fire drill records from November 2022 through September 2023. Written fire drill log did not include problems encountered during any fire drills from November 2022 to September 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed the fire drill policy and discussed changes necessary with Clinical Supervisor and Executive Director on November 9. The fire drill logs were reviewed from this location and it was identified that whomever is facilitating the fire drill needs to document problems encountered, and if there are none they are required to indicate 'NA' in the box. All location staff were informed of this on November 9 and will document accordingly. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to include documentation of medical histories at intake in seven of seven records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Clinical Supervisor reviewed the policy related to medical history as well as the Electronic Health Record program utilized on November 22, 2023. It was identified that medical history can be completed through utilization of a 'Medical Profile' link in the individual's profile. Clinical Supervisor will review this process with all clinical staff and they will begin completing the medical history as part of the biopsychosocial process immediately. Clinical Supervisor and Program Director will be responsible for ensuring this is completed within the three session timeframe of the biopsychosocial.
For all clients active during the review time, staff will complete medical history at the next scheduled individual session with the client beginning on 11/22/23, the date they were notified of this protocol. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to complete initial treatment plans in a timely fashion according to agency policy and procedure manual in four out of seven records.
According to agency policy and procedures, the preliminary treatment plan is completed at intake, initial treatment plan is completed by 30 days, and all additional updates are done every 60 days thereafter.
Client #1 was admitted on March 14, 2023 and discharged on September 25, 2023. Client #1 preliminary treatment plan was completed on March 14, 2023 and initial treatment plan was due by April 13, 2023 but not completed until May 2, 2023.
Client #5 was admitted on April 26, 2023 and still a current client. Client #5 preliminary treatment plan was completed on April 26, 2023 and initial treatment plan was due by May 26, 2023 but not completed until August 1, 2023.
Client #6 was admitted on March 9, 2023 and still a current client. Client #6 preliminary treatment plan was completed on March 9, 2023 and initial treatment plan was due by April 10, 2023 but not completed until April 27, 2023.
Client #7 was admitted on March 16, 2023 and still a current client. Client #7 preliminary treatment plan was completed on March 16, 2023 and initial treatment plan was due by April 17, 2023 but not completed until May 16, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On November 15, 2023 Clinical Supervisor and Program Director discussed deficiencies related to treatment plans of identified clients number 1, 5, 6 and 7. There were no policy issues related to this so citation so no changes will be made related to policy. Clinical Supervisor reviewed policy will all clinical staff during individual supervisions. Quality assurance procedures have been established within the electronic charting program to notify staff one week prior to all treatment plan services being due. Clinical Supervisor and Program Director will assure quality and adherence to policy through electronic monitoring and weekly supervision with individual counselors. |
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 a review of client records, the facility failed to document an attempted follow up with clients following discharge from the facility in one of two applicable records reviewed.
According to agency policy and procedure manual, follow up with discharged clients is as follows: successful discharges are followed up with in six months, unsuccessful or any other type of discharge is followed up with in two weeks.
Client #2 was admitted on April 13, 2023 and discharged against staff advice on June 28, 2023. No follow up attempts were documented for this client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On October 23 Clinical Supervisor and Program Director reviewed the follow-up policy and identified a need for clarification. Effective October 23 Program Director and Clinical Supervisor revised the follow-up policy to include '...any other type of discharge including termination, client choice against facility advice, or relocation..' This change in policy will eliminate ambiguity regarding follow-ups. This policy has been reviewed with all staff during clinical supervision as well as through e-mail notification over the course of the first week of November.
The Clerk Typist will be responsible for maintaining a spreadsheet to track completed follow up contacts. If a follow up is not completed within the two week timeframe the clinical supervisor will document during supervision and Program Director will review policy with the clerk typist. A late follow up will be completed and documented as such.
Program Director will receive weekly tracking spreadsheets from the clerk typists to monitor compliance with the policy and ensure follow ups are being done in an adequate time frame.
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