INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 26-28, 2010 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on May 28, 2010.
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Plan of Correction
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709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of client records, the facility's policies and procedures, and an interview with the facility director, the facility failed to document a discharge summary in 1 of 2 detox client records.
The findings include:
On April 27, 2010 five detox client records were reviewed. A discharge summary was required in two of those records, specifically records # 14 and 15. The facility's policy states that a discharge summary is to be completed within seven days of discharge.
Client # 15 was admitted on March 30, 2010 and discharged on April 3, 2010. As of the date of inspection a discharge summary had not been documented in client record #15.
An interview with the facility director on April 27, 2010 at approximately 4:15 pm confirmed there was no discharge summary present in the reference client record.
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Plan of Correction
Facility Director has re-trained staff on policy that all client records need to have a completed discharge summary within seven days of discharge. Training took place on May 4, 2010.
Compliance will be monitored in regular monthly open and closed chart audits conducted by the Facility Director and the Clinical Coordinator as part of the ongoing Performance Improvement Program with results reported monthly to the Performance Improvement Committee.
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to ensure clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision.
The findings include:
On April 27, 2010 seventeen personnel records were reviewed. Employee #4 was hired on September 8, 2008. A job description for evening clinical supervisor was signed by employee #4 on October 25, 2009. After a review of employee #4's resume, it was found they had less than two years experience as supervisor in a clinical setting. Employee #4's personnel record did not have documentation of a core curriculum in clinical supervision.
On April 28, 2010 an interview was conducted with the human resources director who confirmed that employee number #4 had not received a core curriculum in clinical supervision.
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Plan of Correction
The employee who had not received a core curriculum in supervisory training has been registered to attend the next available Clinical Supervisor Training. The employee will attend the training to be held in Philadelphia on June 7 - 11, 2010. The registration conformation number is 44108. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to document monthly supervisory sessions for each new supervisor for the first six months of employment.
The findings include:
On April 27, 2010 seventeen personnel records were reviewed. Employee #4 was hired on September 8, 2008. A job description for evening clinical supervisor was signed by employee #4 on October 25, 2009. After a review of employee #4's personnel file, it was found that monthly meetings with their supervisor had not been documented for the first six months in that position.
On April 27, 2010 at around 9:15 am, an interview was conducted with the facility director, who confirmed they were employee #4's supervisor and they had not documented their monthly supervisory meetings.
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Plan of Correction
Facility Director has documented all supervisory sessions with clinical supervisors starting in October, 2009 through April, 2010. Facility Director will document monmthly supervisory sessions with all clinical supervisors included in the scope of this standard.
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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 the review of personnel records, the facility failed to document an individual training plan within 30 days for new employees who have been hired after the start of the January 2009 through January 2010 staff training year.
The findings include:
On April 26, 2010 seventeen personnel records were reviewed, eleven of those personnel records, were required to have documentation of an individual training plan within 30 days of their hire date.
Employee #5 was hired on August 24, 2009. A training plan was required to be completed by September 24, 2010. A training plan had not been completed for employee #5 until December 17, 2009.
Employee #6 was hired on April 2, 2009. A training plan was required to be completed by May 2, 2009. A training plan had not been completed for employee #6 until June 23, 2009.
Employee #7 was hired on February 24, 2010. A training plan was required to be completed by March 7, 2010. A training plan had been completed for employee #7, however it was undated and therefore the inspector could not determine if it had been completed timely.
Employee #8 was hired on December 16, 2009. A training plan was required to be completed by January 16, 2010. A training plan had not been completed for employee #8 until March 3, 2010.
Employee #9 was hired on October 16, 2009. A training plan was required to be completed by November 16, 2009. A training plan had not been completed for employee #9 until January 13, 2010.
Employee #11 was hired on April 7, 2009. A training plan was required to be completed by May 7, 2010. A training plan had not been completed for employee #11 until December 11, 2009.
Employee #12 was hired on July 3,2009. A training plan was required to be completed by August 3, 2009. A training plan had not been completed for employee #12 until September 9, 2009.
Employee #13 was hired on September 1, 2009. A training plan was required to be completed by October 1, 2009. A training plan had not been completed for employee #13 until January 26, 2010.
Employee #14 was hired on June 3, 2009. A training plan was required to be completed by July 3, 2009. A training plan had not been completed for employee #14 until December 11, 2009.
Employee #15 was hired on July 22, 2009. A training plan was required to be completed by August 15, 2009. A training plan had not been completed for employee #15 until December 31, 2009.
Employee #17 was hired on November 2, 2009. A training plan was required to be completed by December 2, 2009. A training plan had not been completed for employee #17 until January 15, 2010.
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Plan of Correction
Human Resource Director will ensure that all staff receives an annual training plan within 30 days of the date of hire. A monthly audit by the Human Resource Director of all personnel files will be conducted to ensure compliance.Audit results will be reported monthly to Performance Improvement Committee.
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