INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 29, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Family Services of Warren County, 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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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on the review of the facility's policy and procedures manual, he facility failed to develop policies and procedures which included the ongoing monitoring of the corrective action plan for unusual incidents. The policy and procedure manual was reviewed on June 29, 2021. The manual did not document the required information. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The relevant policy and procedure, "Reporting of Unusual Incidents," will be updated to reflect the following: "4. If the Clinical Supervisor and/or Executive Director determine with or without involved treatment team members at this time that a corrective action plan is to be established, a timely and appropriate corrective action plan shall be issued within five (5) business days.
5. The Executive Director will be responsible for ongoing monitoring of the corrective action plan appropriate for the needs of the particular plan."
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in two out of three discharged records reviewed.Client #5 was admitted on October 13, 2020 and was discharged on January 14, 2021. Client #7 was admitted on October 6, 2020 and was discharged on May 19, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Clinical Supervisor will review the process for documenting follow up services in the next clinical meeting with all Substance Abuse Services Therapists, ensuring that follow up documentation is completed at time of discharge. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display the hours of project operation to the general public. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Hours of operation will be displayed prominently in the front entryway of the facility. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display a telephone number to the general public for emergency purposes. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Emergency telephone numbers will be displayed prominently in the front entryway of the facility in plain view of the general public. |