INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 14, 2023 through February 15, 2023 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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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 a review of personnel records, the facility failed to ensure that the lead counselor, who had not functioned for 2 years as a supervisor in the provision of clinical services, completed a Department-approved core curriculum in clinical supervision in one of one applicable personnel record reviewed.
Employee #24 was promoted as a clinical lead counselor on July 18, 2021 and did not have clinical supervision experience prior to being promoted. There was no documentation of a Department-approved core curriculum in clinical supervision in the record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Lead counselor will register to complete core curriculum training needed to remain in position by next available training date. A date has yet to be posted on DDAP training portal. Director of Clinical Services will continue to monitor portal for upcoming training date on weekly basis. Staff will provide proof of training to Human Resources to be filed in employee record moving forward. Director of Clinical Services will monitor to ensure that within first 12 months of hire, lead counselor will complete core curriculum training. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility to failed to ensure that counselors met the educational and experiential qualifications in one of nine applicable personnel records reviewed.
Employee #10 was hired as a counselor by the facility on June 27, 2022. The employee does have a qualifying associate ' s degree with a major in a related field; however, the employee did not have the required two years of clinical experience in a health or human service agency prior to hiring.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee has been demoted to counselor aide until required experience is achieved. Employee's title has been changed effective 2.15.23. Human Resources and Director of Clinical Services will continue to verify credentialing during onboarding process to ensure appropriate qualifications of counselor position are being followed. Moving forward the Human Resources file will reflect clinical experience and 100% of new hire audits on employee files will be conducted monthly. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training required for counselors during the facility's January 2022 through December 2022 training year in two of ten applicable personnel records reviewed.
Employee #8 was hired as a counselor on October 14, 1985. The personnel record documented 2 hours of annual training during the period reviewed.
Employee #12 was hired as a counselor on November 23, 2020. The personnel record documented 8.5 hours for annual training during the period reviewed.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Human Resources and Director of Clinical Services will continue to monitor that training hours are completed for all positions on annual basis. Staff can utilize Health Stream Training Portal for continuing training and education hours. Employees will complete any outstanding trainings required by the end of their 12-month term. Human Resources will continue to monitor training hours and send out quarterly reminders to Director of Clinical Services so that clinical staff can complete trainings timely. Training needs and training compliance will also be monitored during Performance Improvement committees held monthly. Moving forward the Human Resources file will reflect 25 training hours and 100% of new hire audits on employee files will be conducted monthly. |
704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that the inpatient nonhospital detoxification activity had one FTE primary care staff person available for every seven clients during primary care hours over the course of several days in January 2023.
On January 15, 2023, the inpatient nonhospital detoxification census was 32, which required 5 primary care staff persons available; however, there were only 3 primary care staff available from 4PM to 6PM and 4 primary care staff available from 7PM to 10PM.
On January 19, 2023, the inpatient nonhospital detoxification census was 25, which required 4 primary care staff persons available; however, there were 3 primary care staff available from 1AM to 5AM.
On January 20, 2023, the inpatient nonhospital detoxification census was 29, which required 5 primary care staff persons available; however, there were 2 primary care staff available from 12AM to 1AM, 1 primary care staff available from 1AM to 5AM, and 2 primary care staff available from 6AM to 7AM.
On January 21, 2023, the inpatient nonhospital detoxification census was 31, which required 5 primary care staff persons available; however, there were 3 primary care staff available from 12AM to 6AM.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
KSC will ensure proper staffing overnight and abide by detox staffing throughout each shift so that detox patients also have 24/7 access to primary care staff throughout all shifts. The schedule will be monitored daily by department heads/supervisors. Performance Improvement Director has been reeducated on submission DDAP requirements for staff scheduling. Human Resources will monitor staffing and hire as needed to fulfill requirement of primary care staff ratios in detox units. Staff, to include leadership, will continue to support departments during unexpected call outs or covid positive cases. Barriers to scheduling will be addressed in weekly in FTE meeting. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection conducted on February 15, 2023, the facility failed to ensure that there were slip-resistant surfaces in all bathtubs and showers.
The third-floor communal bathroom and bathrooms in rooms # 201 and #202, located in the Mansion, did not have slip-resistant surfaces.
The communal bathrooms that are located on the first floor and second floor of the Carriage House, did not have slip-resistant surfaces.
The communal bathrooms, located on the first floor Detox Area, did not have slip-resistant surfaces.
The communal bathroom, located in the Main Nursing Station, did not have a slip-resistant surface.
The communal bathroom and the bathroom in room #129, located in the Twin House, did not have slip-resistant surfaces.
The communal bathroom, located on the second floor of the Men's Wing, did not have slip-resistant surfaces.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plant Ops addressed all communal bathrooms and have ensured that all communal bathrooms have slip resistant mats placed within them in designated areas as of March 8, 2023. Plant Ops will monitor inventory to ensure mats are replaced if needed. Plant Ops will monitor this compliance daily during environmental rounds and report any issues in Environment of Care committee held monthly. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a physical plant inspection conducted on February 15, 2023, the facility failed to limit smoking to the designated smoking areas. There were cigarette butts located outside of the emergency exit door of the first floor New Wing area, which leads to the dumpsters and picnic area.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff have been reeducated on importance of patients and employees smoking in designated smoking areas as well as cleanliness of grounds as of 3.8.23. Plant Ops and housekeeping will monitor and ensure that daily ground checks are being done. Plant Ops and Housekeeping will help to support any grounds clean ups as needed. All ground checks compliance will be reported in Patient Safety Council held monthly. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's February 2022 through January 2023 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month for the entire facility/complex during the months of February, May, August, and November 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plant Ops will conduct unannounced fire drills at least once a month for the entire facility/complex. Next unannounced fire drill will take place in month of March. All drills will be reported in monthly Environment of Care committee. Performance Improvement Director will also monitor compliance during monthly Performance Improvement Committee and CEO will also monitor for compliance during monthly supervisions with Director of Plant Ops. |
705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on a review of the February 2022 through January 2023 fire drill logs, the facility failed to conduct fire drills on different days of the week and on different staffing shifts. The facility is residential and provides services 24 hours a day/7 days a week; however, there were no fire drills conducted on Saturday or Sunday during the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plant Ops will conduct unannounced monthly fire drills to include different days of the week at different times of the day and on nights and weekend shifts. Next unannounced fire drill will take place in month of March. All drills will be reported in monthly Environment of Care committee. Performance Improvement Director will also monitor compliance during monthly Performance Improvement Committee. CEO will also monitor for compliance during monthly supervisions with Director of Plant Ops. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in one of fourteen client records reviewed.
Client #6 was admitted to the inpatient nonhospital detoxification activity on February 3, 2023 and was discharged on February 7, 2023. There were release of information forms to a physician and probation and parole that were signed and dated by the client on February 3, 2023; however, the name of the person, agency or organization was not documented on either consent form.
This is a repeat citation from the February 9, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Admissions and Director of Clinical Services have reeducated staff on the importance of proper completion of consents at admission and throughout treatment daily effective 3.8.23. This includes training on ensuring that consents include name of the person or agency/organization in which information is to be disclosed. Admissions will audit name of agency daily for all new admissions. A sample 20 closed and open chart audits will be audited monthly and reviewed during Performance Improvement Committee. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on consent to release information forms in two of fourteen client records reviewed.
Client #8 was admitted to the inpatient residential activity on January 9, 2023 and was active at the time of inspection. A release of information form to an external individual was signed and dated by the client on January 17, 2023; however, the purpose of the disclosure was not documented on the consent form.
Client #13 was admitted to the inpatient residential activity on December 8, 2022 and was discharged on January 1, 2023. A release of information form to another treatment provider was signed and dated by the witness on December 30, 2022; however, the purpose of the disclosure was not documented on the consent form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Admissions and Director of Clinical Services have reeducated staff on the importance of proper completion of consents at admission and throughout treatment daily as of 3.8.23. This includes training on ensuring that purpose of disclosure on the consent. Admissions will audit all new admissions. In addition, a sample of 10 random chart audits will be completed by admissions and 20 random closed and open charts will be audited monthly by Director of Clinical Services and reviewed during Performance Improvement Committee. |
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
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in one of fourteen client records.
Client #13 was admitted to the inpatient residential activity on December 8, 2022 and was discharged on January 1, 2023. A release of information form to another treatment provider was signed and dated by the witness on December 30, 2022; however, the dated signature of the client was no documented on the consent form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Admissions and Director of Clinical Services have reeducated staff on the importance of proper completion of consents at admission and throughout treatment daily as of 3.8.23. This includes training on ensuring that consents contain the date and signature of the client on the consent. Admissions will audit date and signature for all new admissions. In addition, a sample of 10 random chart audits will be completed by admissions and 20 random closed and open charts will be audited monthly by Director of Clinical Services and reviewed during Performance Improvement Committee. |
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 client records, the facility failed to document the date, event, or condition upon which the consent will expire in three of fourteen client records reviewed.
Client #8 was admitted to the inpatient residential activity on January 9, 2023 and was active at the time of inspection. A release of information form to another treatment provider was signed and dated by the client on January 17, 2023; however, the date, event, or condition upon which the consent will expire was not documented on the consent form.
Client #11 was admitted to the inpatient residential activity on October 21, 2022 and was discharged on December 27, 2022. A release of information form to another treatment provider was signed and dated by the client on December 26, 2022; however, the date, event, or condition upon which the consent will expire was not documented on the consent form.
Client #14 was admitted to the inpatient residential activity on November 11, 2022 and was discharged on December 12, 2022. A release of information form to another treatment provider was signed and dated by the client on December 9, 2022; however, the date, event, or condition upon which the consent will expire was not documented on the consent form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Admissions and Director of Clinical Services have reeducated staff on the importance of proper completion of consents at admission and throughout treatment daily as of 3.8.23. This includes training on ensuring that dates of expiration of consent are documented. Admissions will audit date of expiration for all new admission. In addition, a sample of 10 random chart audits will be completed by admissions and 20 random closed and open charts will be audited monthly by Director of Clinical Services and reviewed during Performance Improvement Committee. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client in six of fourteen client records reviewed.
Client #5 was admitted to the inpatient nonhospital detoxification activity on January 9, 2023 and was discharged on January 13, 2023. There were release of information forms to two government agencies, two external individuals, a funding source, a pharmacy, and a urinalysis laboratory that were all signed and dated by the client on January 9, 2023; however, there was no documentation in the records that indicated that a copy of any of the consent forms were offered to the client.
Client #6 was admitted to the inpatient nonhospital detoxification activity on February 3, 2023 and was discharged on February 7, 2023. There were release of information forms to an emergency contact, two funding sources, a physician, a pharmacy, two government agencies, a urinalysis laboratory, and probation and parole that were all signed and dated by the client on February 3, 2023; however, there was no documentation in the record that indicated that a copy of any of the consent forms were offered to the client.
Client #9 was admitted to the inpatient residential activity on January 13, 2023 and was active at the time of inspection. There were release of information forms to two government agencies, two external individuals, a funding source, a pharmacy, and a urinalysis laboratory that were all signed and dated by the client on January 9, 2023; however, there was no documentation in the record that indicated that a copy of any of the consent forms were offered to the client. Additionally, there were two release of information forms to probation and parole that were signed and dated by the client on January 20, 2023; however, there was no documentation in the record that indicated that a copy of any of either consent form was offered to the client.
Client #10 was admitted to the inpatient residential activity on January 25, 2023 and was active at the time of inspection. There were release of information forms to another treatment provider, a physician, and a urinalysis laboratory that were all signed and dated by the client on January 25, 2023; however, there was no documentation in the record that indicated that a copy of any of the consent forms were offered to the client.
Client #11 was admitted to the inpatient residential activity on October 21, 2022 and was discharged on December 27, 2022. There was a release of information form to a government agency that was signed and dated by the client on October 21, 2022; however, there was no documentation in the record that indicated that a copy of the consent form was offered to the client. Additionally, there was a release of information form to another treatment provider that was signed and dated by the client on December 26, 2022; however, there was no documentation in the record that indicated that a copy of the consent form was offered to the client.
Client #13 was admitted to the inpatient residential activity on December 8, 2022 and was discharged on January 1, 2023. A release of information form to another treatment provider was signed and dated by the witness on December 30, 2022; however, there was no documentation in the record that indicated that a copy of the consent form was offered to the client.
This is a repeat citation from the February 9, 2023 annual renewal inspection
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Admissions and Director of Clinical Services have reeducated staff on the importance of proper completion of consents at admission and throughout treatment daily as of.8.23.. This includes training on ensuring that consents indicate that a copy was offered to the client. Admissions will audit for indication of a copy offered to client for all new admission. In addition, a sample of 10 random chart audits will be completed by admissions and 20 random closed and open charts will be audited monthly by Director of Clinical Services and reviewed during Performance Improvement Committee. |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's February 2022 through February 2023 unusual incident logs, the facility failed to notify the Department within 3 business days of 36 incidents of physical altercation or aggression during the reviewed period. Additionally, the facility failed to notify the Department within 3 business days of 29 incidents of sexual assault or misconduct during the reviewed period.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Performance Improvement Director was reeducated on the importance of reporting all physical or sexual assault unusual incidences to the state within 3 business days as of 2.16.23. CEO reviewed licensing alert 02-2018- Reporting of Unusual incidences with leadership team as of 2.20.23. Performance Improvement Director will maintain a daily log of detailed reports and information pertinent to each incident. Risk Manager and Performance Improvement Director will continue to monitor internal submissions of incidences which will be reviewed and discussed in Patient Safety Council meetings held monthly. |
709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of the facility's February 2022 through February 2023 unusual incident logs, the facility failed to notify the Department within 3 business day of 4 client deaths during the reviewed period.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Performance Improvement Director was reeducated on the importance of reporting all death or serious injury due to trauma, suicide, medication errors or unusual circumstances to the state within 3 business days as of 2.16.23. CEO reviewed licensing alert 02-2018- Reporting of Unusual Incidences with leadership team as of 2.20.23. Performance Improvement Director will maintain a daily log of detailed reports and information pertinent to each incident. Risk Manager and Performance Improvement Director will continue to monitor internal submissions of incidences which will be reviewed and discussed in Patient Safety Council meetings held monthly. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to complete an individual treatment and rehabilitation plan, which is to be developed with the client, in one of six applicable client records reviewed. Additionally, the facility failed to complete an individual treatment and rehabilitation plan within the timeframe documented in the facility policy and procedure manual in one of six applicable client records reviewed.
Client #9 was admitted to the inpatient residential activity on January 13, 2023 and was active at the time of inspection. There was no individual treatment rehabilitation plan, in the record, as of the date of inspection.
Client #10 was admitted to the inpatient residential activity on January 25, 2023 and was active at the time of inspection. The policy and procedure manual stated that the comprehensive treatment plan will be completed within 72 hours of admission. The comprehensive treatment plan for this client was due no later than January 28, 2023; however, the plan was completed on January 30, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Clinical Services will continue to reeducate staff on importance of timeliness of treatment plans during length of stay. These expectations are reviewed weekly during chart audits with Director of Clinical and Performance Improvement. Director. Director of Clinical Services will continue to conduct daily open chart audits. Treatment plan compliance will be monitored by Performance Improvement Committee monthly while reviewing a sample of 20 closed and open chart audits. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 15 days for projects whose client treatment regime is less than 30 days in three of six applicable client records reviewed.
Client #8 was admitted to the inpatient residential activity on January 9, 2023 and was active at the time of inspection. A treatment plan update was completed on January 23, 2023 and the next update was due no later than February 7, 2023; however, the update was not completed at the time of inspection.
Client #9 was admitted to the inpatient residential activity on January 13, 2023 and was active at the time of inspection. A treatment plan update was completed on January 26, 2023 and the next update was due no later than February 10, 2023; however, the update was not completed at the time of inspection.
Client #11 was admitted to the inpatient residential activity on October 21, 2022 and was discharged on December 27, 2022. A treatment plan update was completed on November 4, 2022 and the next update was due no later than November 19, 2023; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Clinical Services will continue to reeducate staff on importance of timeliness of treatment plans during length of stay to ensure they are updated at required frequency. These expectations are reviewed weekly during chart audits with Director of Clinical Services and Performance Improvement Director. Director of Clinical will continue to conduct daily open chart audits. Treatment plan compliance will be monitored by Performance Improvement Committee monthly while reviewing a sample of 20 closed and open chart audits. |
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 being provided according to the individual treatment and rehabilitation plan in three of six applicable client records reviewed.
Client #8 was admitted to the inpatient residential activity on January 9, 2023 and was active at the time of inspection. The comprehensive treatment plan, dated January 9, 2023, documented weekly individual counseling sessions. There was no documentation, in the record, of individual counseling sessions occurring during the weeks of January 15, 2023 through February 11, 2023.
Client #9 was admitted to the inpatient residential activity on January 13, 2023 and was active at the time of inspection. A treatment plan update dated January 26, 2023, documented weekly individual counseling sessions. There was no documentation, in the record, of individual counseling sessions occurring during the week of January 29, 20223 through February 4, 2023.
Client #10 was admitted to the inpatient residential activity on January 25, 2023 and was active at the time of inspection. The comprehensive treatment plan dated January 30, 2023 and a treatment plan update dated February 13, 2023, both documented weekly individual counseling sessions. There was no documentation, in the record, of individual counseling sessions occurring during the week of February 5, 2023 through February 11, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Clinical Services reeducated clinical staff on abiding by individual session timeframes and frequency during treatment stay as of 2.16.23 per policy. The compliance of individual session requirements will be monitored during weekly chart audits with Director of Clinical Services and Performance Improvement Director. This will be monitored by Performance Improvement Committee monthly while reviewing a sample of 20 closed and open chart audits. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include follow-up information, in one of one applicable client record reviewed.
Client #13 was admitted to the inpatient residential activity on December 8, 2022 and was referred out and discharged on January 1, 2023. The policy and procedure manual stated that follow-up for referred clients will be completed within a week of discharge. Follow-up was due no later than January 8, 2023; however, there was no documentation of follow-up being completed at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff has been reeducated as of 3.3.23 on importance of follow up calls after discharge within one week of discharge per state timeframes in order to maintain a complete client record . This compliance will be monitored during audits while reviewing a sample of ten closed charts monthly and findings will be reviewed for compliance during Performance Improvement Committee held monthly. |