INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29, 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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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 training annually during the facility's January 1, 2020 through December 31, 2020 training year in one of four applicable records.
Employee # 15 was hired as a counselor on October 27, 2015. The personnel record documented 21 hours and 19 minutes of training during the 2020 training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
704.11
Human Resource Director will insure that all counselors complete at least 25 clock hours of training annually. Human Resources Director will perform quarterly audits of training hours for clinical staff to assure compliance. Human Resources Director will also provide Clinical Director audit information to keep Clinical Director up to date in regards to training hours completed and needed for clinical staff. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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
Based on a review of the facility's February 2020 through December 2020 fire drill log, the facility failed to ensure that their written fire drill log included the amount of time it took for evacuation and the exit route used. The March 2020 drill log did not record the amount of time it took for evacuation and the December 2020 drill log did not record the exit route used.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
705.10
The Director of Plant Operations will retrain staff on how to properly complete the fire drill logs. The fire drill logs have been updated to include the start time and end time of the drill. The Director of Plant Operations will ensure the exit route locations are properly documented. The fire drill logs will be monitored by the Director of Plant Operations month to month, to ensure all information is accounted for properly on the fire drill logs. The Director of Plant Operations will bring all fire drill logs to safety council monthly to audit that the logs have been fully documented ongoing. |
715.8(1)(i)(A) LICENSURE Psychosocial Staffing
A narcotic treatment program shall comply with the following staffing ratios as established in Chapter 704 (relating to staffing requirements for drug and alcohol treatment activities):
(1) General requirements. A narcotic treatment program shall comply with the patient/staff and patient/counselor ratios in subparagraphs (i)-(vi) during primary care hours. These ratios refer to the total number of patients being treated, including patients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one patient.
(i) Inpatient nonhospital detoxification (residential detoxification).
(A) There shall be one full-time equivalent (FTE) primary care staff person available for every seven patients during primary care hours.
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Observations
Based on a review of administrative documents, the facility failed to ensure that there was one FTE primary care staff person available for every seven patients during primary care hours.
On December 9, 2020, the inpatient nonhospital detoxification census was 19 which requires 3 primary care staff persons to be available; however, there were only 2 primary care staff persons available from 12 AM to 6 AM.
On December 12, 2020, the inpatient nonhospital detoxification census was 21 which requires 3 primary care staff persons to be available; however, there were only 2 primary care staff persons available from 12 AM to 6 AM.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
715.8
Keystone's Chief Nursing Officer has immediately corrected all ongoing staffing deficiencies for patient to staff ratios. Further, Keystone Center has on boarded Full Time, Part Time and PRN nursing staff since the inspection as well as contracted with an outside staffing agency to remedy any future possibilities for deficiencies in our rations.
The Chief Nursing Officer will report staffing ratios each month in performance improvement meetings with leadership to ensure that appropriate ratio requirements are met moving forward. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to maintain a complete file for each patient, which is to include a discharge summary, in three of four applicable client records.
Client #10 was admitted on October 7, 2020 and was discharged on November 1, 2020. There was no discharge summary documented in the client record.
Client #11 was admitted on October 13, 2020 and was discharged on November 3, 2020. There was no discharge summary documented in the client record.
Client #14 was admitted on November 30, 2020 and was discharged on December 13, 2020. There was no discharge summary documented in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
715.23
The Director of Clinical Services will provide re-education of staff regarding the Rules and Regulations to include the requirements for a discharge summary to be completed for all patients within 7 days of discharge. Training was completed individually and/or in small groups.
Director of Clinical Services will complete 30 closed chart audits a month which will include looking at the discharge summary and providing reminders in monthly staff meetings.
The Clinical Director reports aggregated data and relevant action plans regarding the timely completion of discharge summaries which is reported to Performance Improvement monthly and the Governing Body quarterly. |