INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 3, 2022 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) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's January 2021 through January 2022 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts. The facility's hours of operation are Monday through Thursday 9:00AM - 8:30PM and Friday 9:00AM - 2:00PM. None of the fire drills conducted, during the reviewed period, were completed during the evening hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Plant Operations was provided with training by Director of Quality Assurance on 2/4/2022 regarding the requirement to conduct fire drills different times of day to align with facility evening hours of operations.
As a monitoring measure, the Director of Plant Operations will track all fire drills to ensure different days and times as well as different staffing shifts. This data will be reported monthly to the Environment of Care Committee. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #2 was admitted on March 18, 2021 and was active at the time of inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately following the exit interview on 2/3/2022, the Director of Outpatient Services provided individual retraining to the intake counselor and; the release of information for the funding source was obtained and placed in the client record on 2/4/2022.
Director of Outpatient Program will re-educate and re-train all other program staff to obtain and appropriately file all releases of information within the client record by 3/2/2022.
Ongoing, Director of Outpatient Program will monitor through monthly audits of charts ensuring the compliance for releases of information being fully filled out and filed per policy and standards. Compliance of the audits will be reported monthly within the Performance Improvement Committee.
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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 seven client records reviewed.
Client #3 was admitted on March 30, 2021 and was active at the time of inspection. A blank release of information form was signed and dated by the client on March 30, 2021; however, the name of the person, agency or organization to whom the disclosure was to be made to was not documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training was initiated on 2/11/2022 by The Director of Outpatient Services to all clinical staff on the proper completion of such forms as detailed in facility policy. Any clinical staff member that is not able to attend the scheduled trainings will do so on or before 3/2/2022 or thereafter before their next worked shift to assure understanding.
Ongoing, Director of Outpatient Program will monitor through monthly audits of charts ensuring the compliance for releases of information being fully filled out per policy and state standards. Compliance of the audits will be reported monthly within the Performance Improvement Committee.
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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
Based on a review of client records, the facility failed to keep consent to release information forms within the limits established by 4 Pa. Code 255.5 (b) for releases of information in three of seven client records reviewed.
Client #4 was admitted on April 8, 2021 and was discharged on December 3, 2021. Release of information forms to a government agency and a funding source were signed and dated by the client on April 8, 2021 that allowed for the release of the aftercare plan, which exceeded the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to a government agency was signed and dated by the client on April 8, 2021 that allowed for the release of the aftercare appointment, which exceeded the limits established by 4 Pa. Code 255.5.
Client #6 was admitted on April 22, 2021 and was discharged on November 3, 2021. A release of information form to a funding source was signed and dated by the client on April 22, 2021 that allowed for the release of the aftercare plan, which exceeded the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to a government agency was signed and dated by the client on April 22, 2021 that allowed for the release of the aftercare appointment, which exceeded the limits established by 4 Pa. Code 255.5.
Client #7 was admitted on July 15, 2021 and was discharged on November 17, 2021. Release of information forms to a government agency and a funding source were signed and dated by the client on July 15, 2021 that allowed for the release of the aftercare plan, which exceeded the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to a government agency was signed and dated by the client on July 15, 2021 that allowed for the release of the aftercare appointment, which exceeded the limits established by 4 Pa. Code 255.5.
This is a repeat citation from the January 5, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Outpatient Program will re-educate and re-train all program staff on confidentiality procedures and policies as well as the limits established by 4 Pa. Code 255.5 by 3/2/2022. Training was initiated on 2/11/2022 by The Director of Outpatient Services to all clinical staff on the proper completion of such forms and authorized disclosure as detailed in facility policy. Any clinical staff member that is not able to attend the scheduled trainings will do so on or before 3/2/2022 or thereafter before their next worked shift to assure understanding
Ongoing, Director of Outpatient Program will monitor through monthly audits of charts ensuring the compliance for releases of information being fully filled out per policy and state standards. Compliance of the audits will be reported monthly within the Performance Improvement Committee.
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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 client records, the facility failed to document the date, event or condition upon which the consent will expire on release of information forms in one of seven client records reviewed.
Client #1 was admitted on April 1, 2021 and was active at the time of inspection. A release of information form to a funding source was signed and dated by the client on April 1, 2021; however, the date, event or condition upon which the consent will expire was not documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Outpatient Program will re-educate and re-train all program staff to fully fill out forms per policy and state standards by 3/2/2022. Training was initiated on 2/11/2022 by The Director of Outpatient Services to all clinical staff on the proper completion of such forms and completion of expiration dates within the release as detailed in facility policy. Any clinical staff member that is not able to attend the scheduled trainings will do so on or before 3/2/2022 or thereafter before their next worked shift to assure understanding Ongoing, Director of Outpatient Program will monitor through monthly audits of charts ensuring the compliance for releases of information being fully filled out per policy and state standards. Compliance of the audits will be reported monthly within the 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 ensure that a copy of a client consent to release information form was offered to the client in three of seven client records reviewed.
Client #1 was admitted on April 1, 2021 and was active at the time of inspection. Release of information forms to an emergency contact, two government agencies, a funding source, and a urinalysis laboratory were signed and dated by the client on April 1, 2021; however, there was no documentation that a copy of any of the forms were offered to the client.
Client #2 was admitted on March 18, 2021 and was active at the time of inspection. Release of information forms to an emergency contact, two government agencies, and a urinalysis laboratory were signed and dated by the client on March 18, 2021; however, there was no documentation that a copy of any of the forms were offered to the client.
Client #3 was admitted on March 30, 2021 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on March 30, 2021; however, there was no documentation that a copy of the form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training was initiated on 2/11/2022 by The Director of Outpatient Services to all clinical staff on the necessity to document the offering of a copy of each consent as well as the proper completion of such forms as detailed in facility policy. Any clinical staff member that is not able to attend the scheduled trainings will do so on or before 3/2/2022 or thereafter before their next worked shift to assure understanding.
Director of Outpatient Program will re-educate and re-train all program staff to fully fill out forms per policy and state standards by 3/2/2022.
Ongoing, Director of Outpatient Program will monitor through monthly audits of charts ensuring the compliance for releases of information being fully filled out per policy and state standards. Compliance of the audits will be reported monthly within the Performance Improvement Committee.
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