INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 12, 2024 through December 13, 2024 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on review of client records and the policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in nine of thirteen applicable client records reviewed.
First, the policy and procedure manual stated that the psychosocial assessments will be completed within three to five days of the nursing assessment, which is completed within 24 hours of admission.
Client # 1 was admitted to the detoxification level of care on November 21, 2024 and was transferred to a lower level of care on November 26, 2024. The record contained a psychosocial assessment; however, it was not dated to confirm it was completed according to the timeframe of the facility policy.
Client # 4 was admitted to the detoxification level of care on November 14, 2024 and was transferred to a lower level of care on November 19, 2024. The record contained a psychosocial assessment; however, it was not dated to confirm it was completed according to the timeframe of the facility policy.
Client # 6 was admitted to the detoxification level of care on August 20, 2024 and was transferred to a lower level of care on August 25, 2024. The record contained a psychosocial assessment; however, it was not dated to confirm it was completed according to the timeframe of the facility policy.
Client # 7 was admitted to the detoxification level of care on November 30, 2024 and was active at the time of the inspection. The record contained a psychosocial assessment; however, it was not dated to confirm it was completed according to the timeframe of the facility policy.
Client # 12 was admitted to the inpatient level of care on November 14, 2024 and was active at the time of the inspection. The record contained a psychosocial assessment; however, it was not dated to confirm it was completed according to the timeframe of the facility policy.
Client # 13 was admitted to the inpatient level of care on September 27, 2024 and was discharged on October 15, 2024. The record contained a psychosocial assessment; however, it was not dated to confirm it was completed according to the timeframe of the facility policy.
Client # 14 was admitted to the inpatient level of care on August 23, 2024 and was discharged on September 20, 2024. The record contained a psychosocial assessment; however, it was not dated to confirm it was completed according to the timeframe of the facility policy.
Second, the policy and procedure manual stated that follow-up attempts are to occur within seven days of discharge when a referral is made.
Client # 5 was admitted to the detoxification level of care on October 20, 2024 and was discharged on October 27, 2024. The record contained follow-up information; however, it was not dated to confirm it was completed within the timeframe of the facility policy.
Client # 10 was transferred to the inpatient level of care on September 18, 2024 and was discharged on October 19, 2024. The record contained follow-up information; however, it was not dated to confirm it was completed within the timeframe of the facility policy.
This is a repeat citation from the December 6, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors were immediately re-educated on timely documentation within the medical record including completing the documentation by dating the documents' completion date as well as completing follow-up attempts timely.
Ongoing, the Director of Performance Improvement and Director of Clinical Services will monitor and audit 30 charts per month for timeliness and completeness of the biopsychosocial assessments and follow-ups post discharge. Audit results will be reported through the Performance Improvement Committee monthly. Any deficiencies will be addressed through education and correction action where indicated.
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of thirteen client records, the facility failed to ensure that consent to release information forms included the date, event, or condition upon which the consent will expire in two records reviewed.
Client # 5 was admitted to the detoxification level of care on October 20, 2024 and was discharged on October 27, 2024. The record contained consent to release information forms to an employer and a school signed by the client on October 21, 2024 that were missing the date, event, or condition upon which the consent will expire.
Client # 13 was admitted to the inpatient level of care on September 27, 2024 and was discharged on October 15, 2024. The record contained a consent to release information form to a treatment provider signed by the client on October 15, 2024 that were missing the date, event, or condition upon which the consent will expire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of QA immediately re-educated all staff on the Therapist's Team of the requirement for dated signature as well as expiration date by the client and staff on each release of information.
Ongoing, the Director of QA and Director of Clinical Services will monitor and audit 30 charts per month for to each client signatures on the release forms including a date and expiration date as required. Audit results will be reported through the Performance Improvement Committee monthly. Any deficiencies will be addressed through education and correction action where indicated. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of client records and discussion with facility staff, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire, or ambulance personnel.
There was documentation of the presence of ambulance personnel on December 8, 2024; however, there was no documentation that a written unusual incident report was ever filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Director of Risk Management will upload the incident report to the DDAP UIR portal immediately.
The Director of Risk Management and Director of Quality Assurance were all immediately re-educated of the policy of unusual incidents and DDAP regulation 709.3 (c) (4); specifically any transports to the ER via an ambulance.
Ongoing, Incidents will be reviewed and reported in Keystone Center's daily leadership meeting. Incidents requiring reporting will be identified by leadership and will be reported timely by the Director of Risk Management. Compliance with timely incident reporting will be reported monthly through Performance Improvement Committee. |
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 failed to ensure a complete client record included information relative to the client's involvement with the project, to include a discharge summary, in one of two applicable records reviewed.
Client # 5 was admitted to the detoxification level of care on October 20, 2024 and was discharged on October 27, 2024. The record did not contain a discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Primary Therapists were immediately re-educated on completing the discharge summaries timely.
Ongoing, the Director of Performance Improvement and Director of Clinical Services will monitor and audit 30 charts per month for timeliness of the treatment plan updates. Audit results will be reported through the Performance Improvement Committee monthly. Any deficiencies will be addressed through education and correction action where indicated.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in four of eight applicable records reviewed.
Client # 10 was transferred to the inpatient level of care on September 18, 2024 and was discharged on October 19, 2024. The treatment plan completed on September 13, 2024 in a higher level of care, indicated that the client was to receive one individual session per week; however, the record did not document individual sessions offered between September 13, 2024 and September 25, 2024.
Client # 13 was admitted to the inpatient level of care on September 27, 2024 and was discharged on October 15, 2024. The treatment plan completed on October 3, 2024, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session between October 3, 2024 and the date of discharge.
Client # 15 was transferred to the inpatient level of care on August 25, 2024 and was discharged on September 12, 2024. The treatment plans completed on August 23, 2024 in a higher level of care and September 5, 2024, indicated that the client was to receive one individual session per week; however, the record did not contain documentation that any individual sessions were offered prior to discharge.
Client # 17 was admitted to the inpatient level of care on November 2, 2024 and was discharged on November 27, 2024. The treatment plan completed on November 5, 2024, indicated that the client was to receive one individual session per week; however, the record did not document individual sessions offered between November 5, 2024 and November 19, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Primary Therapists were immediately re-educated on completing individual session documentation timely.
Ongoing, the Director of Performance Improvement and Director of Clinical Services will monitor and audit 30 charts per month for completeness and timeliness of individual session documentation. Audit results will be reported through the Performance Improvement Committee monthly. Any deficiencies will be addressed through education and correction action where indicated.
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