INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone/ buprenorphine monitoring inspection conducted on November 24-25, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, UPMC McKeesport Hospital 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 records, the facility failed to 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: A mechanism to collect feedback on completed training and an annual evaluation of the overall training plan.This finding was reviewed with facility staff during the licensing process.This is a repeat citation from the November 26, 2024 licensing inspection.
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Plan of Correction
Individualized Annual Training Plans and Annual Training Assessments
Annual Training Assessment and Individualized Annual Training Plans will follow the same schedule as system wide annual mandatory trainings.
a. Training period runs from October 31st through September 1st.
i. Assessment and Planning sheets will be distributed to staff on the closest business day to October 31st if it falls on a holiday or weekend day.
b. Copies of Training Plans and Assessments located in References Section as Attachments 1 and 2.
Annual Training Assessments and Annual Training Plans will be completed by staff and returned to unit leadership directly, during monthly 1:1's, or into the return bin located in the unit's workstation.
Unit leadership will utilize the following methods to evaluate the overall training plans.
Staff will complete an evaluation of their completed training(s) and submit within 30 days.
The evaluation will be a standard tool and need for each training.
Unit leadership will review evaluation, identify trends to utilize and adjust tentative training as needed.
Unit leadership will discuss evaluation in 1:1 meeting.
Training plans will be specific to the discipline of those completing (i.e. Social Services, Nursing, Support Staff). |
710.22(c) LICENSURE Patient Management Services
§ 710.22. Patient management services.
(c) The service staff shall develop a written patient follow-up policy.
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Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against medical advice in the detoxification level of care in one of one applicable records.The facility's policy and procedure states the client ' s emergency contact will be notified within 12 hours of the client ' s decision to leave against facility advice, providing there is consent given in writing to contact the emergency contact.Client #4 was admitted to the detoxification level of care on October 17, 2025, and discharged on October 20, 2025. There was a consent for the emergency contact in the client record but no documented attempt to contact emergency contact following discharge.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
On admission patients sign a form that give staff permission to either notify or not their emergency contact if they would choose to left AMA.
Several employees will confirm that this has taken place so this is not missed effective 12/1/2025.
Social service will confirm with nursing that they made the call. Social service will document the response they receive from nursing. If nursing had not made the call, social service would have made the call.
If nursing made the call nursing will document who they spoke to.
When patient and family concierge are taking the chart apart upon departure of patient, they will also check to make sure the call was made by social service or nursing.
This will go through 3 individuals to assure this step is not getting missed. |
710.41(a)(4) LICENSURE Admission - Treatment and Rehabilitation
§ 710.41. Admission-treatment and rehabilitation.
(a) The service director shall develop a written plan providing for admission which shall include, but not be limited to, the following:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against medical advice in the residential level of care in one of two applicable records.The facility's policy and procedure states the client ' s emergency contact will be notified within 12 hours of the client ' s decision to leave against facility advice, providing there is consent given in writing to contact the emergency contact.Client #10 was admitted to the residential level of care on September 29, 2025, and discharged on October 3, 2025. There was a consent for the emergency contact in the client record but no documented attempt to contact emergency contact following discharge.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
On admission patients sign a form that give staff permission to either notify or not their emergency contact if they would choose to left AMA.
Several employees will confirm that this has taken place so this is not missed effective 12/1/2025.
Social service will confirm with nursing that they made the call. Social service will document the response they receive from nursing. If nursing had not made the call, social service would have made the call.
If nursing made the call nursing will document who they spoke to.
When patient and family concierge are taking the chart apart upon departure of patient, they will also check to make sure the call was made by social service or nursing.
This will go through 3 individuals to assure this step is not getting missed. |