INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 5, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, UHS Recovery Foundation, 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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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
The facility failed to ensure that their written fire drill record included the amount of time it took for evacuation and the number of person in the facility at the time of the drill. Based on the review of the February 2020 through December 2020 fire drill records, every fire drill log did not record the number of persons in the facility at the time of the drill and the May 2020, July 2020, August 2020, September 2020 and December 2020 fire drill logs did not record the amount of time it took for evacuation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility fire record will be revised to include the amount of time for evacuation and the number of person in the facility at the time of the drill. Director of Plant Observation will be responsible for revising the fire record template.
The DPO will audit 100% of fire drill evaluations to verify "amount of time for evacuation and the number of persons in the facility at the time of drill" are included.
Aggregated data regarding completion of fire drill evaluation will be reported by the DPO monthly to the PI Committee.
1/18/21
Status: Complete
Date: 1/18/21
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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
The facility failed to ensure that all consent to release information forms documented the specific information to be disclosed in three of seven client records reviewed.
Client # 2 was admitted on July 2, 2020 and was still active at the time of inspection. The release of information forms to the funding sources, another treatment provider, and government agencies were dated on July 2, 2020.
Client # 3 was admitted on June 16, 2020 and was still active at the time of inspection. The release of information forms to the funding source, another treatment provider, and a government ageny were dated on June 16, 2020.
Client # 4 was admitted on June 9, 2020 and was still active at the time of inspection. The release of information forms to the funding source and the emergency contact were dated on June 8, 2020.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
Key Recovery's release of information form has a category "Other". Next to "Other" there is a space to define what that is. The Director of Clinical Services will educate and train all staff to document the specificity of what "Other" is on the release of information form. This will be done in the next all staff meeting. The Director of Clinical Services will audit 10 open and closed medical records to verify "Other" is defined to what that is. Identified deficiencies will be addressed individually through re-education/corrective counseling by the Director of Clinical Services. These audits will continue until our next DDAP survey in 2022.
Compliance will be monitored monthly during our Performance Improvement committee meeting
Completion Date: Ongoing
Status: Audit Will Start in our January 2021 Performance Improvement Meeting
Date: 1/21/21
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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
The facility failed to ensure that all consent to release information forms documented the dated signature of the client in seven of seven client records reviewed.
Client #1 was admitted on July 28, 2020 and was still active at the time of the inspection. The release of information forms to the emergency contact, a physician, the laboratory, other treatment providers, the funding source and a government agency were signed and dated by the witness on July 28, 2020.
Client #2 was admitted on July 2, 2020 and was still active at the time of the inspection. The release of information forms to the emergency contact, a physician, the laboratory, other treatment providers, the funding sources and government agencies were signed and dated by the witness on July 28, 2020.
Client #3 was admitted on June 16, 2020 and was still active at the time of the inspection. The release of information forms to the emergency contact, a physician, the laboratory, other treatment providers, the funding source, the parole officer and a government agencies were signed and dated by the witness on June 16, 2020.
Client #4 was admitted on June 9, 2020 and was still active at the time of the inspection. The release of information forms to the emergency contact, a physician, the laboratory, other treatment providers, the funding source, the parole officer and a government agencies were signed and dated by the witness on June 8, 2020.
Client #5 was admitted on April 28, 2020 and was discharged on December 23, 2020. The release of information forms to the emergency contact, a physician, the laboratory, other treatment providers, the funding source, the parole officer and a government agency were signed and dated by the witness on April 28, 2020.
Client #6 was admitted on November 25, 2020 and was discharged on December 10, 2020. The release of information forms to the emergency contact, the laboratory, the funding source and a government agency were signed and dated by the witness on November 25, 2020.
Client #7 was admitted on March 24, 2020 and was discharged on December 2, 2020. The release of information forms to the emergency contact, a physician, the laboratory, other treatment providers, the funding source, the parole officer and a government agency were signed and dated by the witness on March 24, 2020.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Key Recovery will have all patients sign the release of information for all necessary parties when they arrive to complete their initial urine drug screens. This will start effective immediately. The Director of Clinical Services will audit 10 open and closed medical records to verify that the Release of Information has been signed by staff and patient. Identified deficiencies will be addressed individually through re-education/corrective counseling by the Director of Clinical Services. These audits will continue until our next DDAP survey in 2022.
Compliance will be monitored monthly during our Performance Improvement committee meeting
Completion Date: Ongoing
Status: Audit Will Start in our January 2021 Performance Improvement Meeting
Date: 1/21/21
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709.93(a)(5) 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:
(5) Progress notes.
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Observations
The facility failed to maintain a complete client record on an individual, which is to include progress notes, in three of seven client records.
Client #2 was admitted on July 2, 2020 and was still active at the time of the inspection. The record of service indicated that the client received counseling sessions on October 28, 2020, November 2, 2020, November 11, 2020 and November 18, 2020; however, there were no corresponding progress notes in the client record for these dates.
Client #3 was admitted on June 16, 2020 and was still active at the time of the inspection. The record of service indicated that the client received counseling sessions on September 7, 2020, September 9, 2020, October 7, 2020, October 19, 2020, October 26, 2020 and October 28, 2020; however, there were no corresponding progress notes in the client record for these dates.
Client #4 was admitted on June 9, 2020 and was still active at the time of the inspection. The record of service indicated that the client received counseling sessions on August 3, 2020, August 5, 2020, August 10, 2020, August 19, 2020, September 14, 2020, September 21, 2020, and September 28, 2020; however, there were no corresponding progress notes in the client record for these dates.
These findings were reviewed with facility staff during the licensing
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Plan of Correction
Plan of Correction:
Key Recovery will maintain a complete client record which includes progress notes for each session the client attends. The Director of Clinical Services will educate and train all staff to document the each session the patient attends via progress notes. This will be done in the next all staff meeting. The Director of Clinical Services will audit 10 open and closed medical records to verify progress notes are completed for each group attended. Identified deficiencies will be addressed individually through re-education/corrective counseling by the Director of Clinical Services. These audits will continue until our next DDAP survey in 2022.
Compliance will be monitored monthly during our Performance Improvement committee meeting.
Completion Date: Ongoing
Status: Audit Will Start in our January 2021 Performance Improvement Meeting
Date: 1/21/21
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