INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 28 - 30, 2008 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 June 4, 2008.
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Plan of Correction
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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 on April 28, 2008, the facility failed to document that one counselor met the qualifications for the position of counselor, #4
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Plan of Correction
Employee meets qualification for counselor as 5/20/08. Human Resource Director will review all new hire qualifications to meet standard including relevant experience, and degree/ credential prior to hire date. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of facility policy and training records on April 28, 2008, the facility failed to document training needs assessments within the required time frame for each employee in three of four records reviewed, #2, 3 and 4. The assessment of training needs forms did not include the employee's name nor the date on which the assessment form was completed.
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Plan of Correction
The assessment form has been revised to include date and time employee completes form. Training was held on 6/18/2008 with department heads to review changes on form. The Director of Human Resources will conduct this training. No forms will be accepted without date and signatures. A quarterly personnel file audit will be completed by the Director of Human Resources, with results reported quarterly to the Performance Improvement Committee. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on May 1, 2008, the facility failed to document complete psychosocial evaluations in two of three client records reviewed, #1 and 3. Psychosocial evaluations were a repeat of historical data and did not include a clinical assessment of the client's assets/strengths, support systems, negative factors that may inhibit treatment and the client's attitude toward treatment.
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Plan of Correction
Intensive in-service training will be given to all outpatient staff on June 12, 2008 to reinforce the importance of including a clinical assessment that include the strengths, support system and any negative factors that could inhibit treatment. Client's attitude toward treatment and perception of their problem should also be reinforced.
Program director and site manager will ensure compliance by monitoring this in the monthly Performance Improvement process.
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records on May 1, 2008, the facility failed to document a treatment plan update in one of one client record reviewed, #1.
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Plan of Correction
In-service training on the requirements of timeliness of treatment plans and updates will be given on June 12, 2008 to all ambulatory staff. The training will be conducted by the Director of Outpatient Services. Implementation and compliance will be ensured by the Program Director. Treatment Plan Updates will continue to be part of the monthly chart audit process, with results reported to the Performance Improvement Committee. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. 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 on May 1, 2008, the facility failed to document that counseling services were provided according to the treatment plan in two of three client records reviewed, #1 and 3. Treatment plans prescribed one individual session per week. Client #1 received only two individual sessions during eight weeks in treatment. Client #3 did not receive any individual sessions during four weeks while in treatment.
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Plan of Correction
Treatment plan training on 6/12/2008, held by the Program Director, will include a review of the regulation that an outpatient client is to receive one individual session per month and this is to be documented on the treatment plan. The number of individuals that a client is to receive and corresponding service record should record those or identify that the client failed to show for the scheduled appointment. Implementation will be ensured by the Program Director. Program Director and Site Manager will ensure compliance by monitoring this in the monthly Performance Improvement process. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records on May 1, 2008, the facility failed to document at least two individual counseling sessions per week in two of three client records reviewed, #1 and 3.
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Plan of Correction
In-service training on the requirements of timeliness of treatment plans and updates will be given on June 12, 2008 to all ambulatory staff, by the Program Director. This training will emphasize the regulation for two individuals per week in the partial hospitalization setting. Implementation of this information will be ensured by the Program Director. Program Director and Site Manager will ensure compliance by monitoring via monthly chart audits and will report results to the Performance Improvement Committee. |
709.83(a)(11) LICENSURE Client records
709.83. 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 on May 1, 2008, the facility failed to document follow-up information in two of two client records reviewed, #1 and 3. Follow-up information was missing.
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Plan of Correction
In-service training on follow up protocol for all clients at Key Recovery will be given on June 26, 2008 for all ambulatory staff. This training will be conducted by the Program Director. Implementation of this information will be ensured by the Program Director. Program Director and Site Manager will ensure compliance by monitoring this in the monthly Performance Improvement process via chart audits. |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based on a review of personnel records on May 1, 2008, the facility failed to document that employees were informed of their rights in four of five personnel records reviewed, #2, 3, 4 and 5.
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Plan of Correction
A sign off sheet was created; employees will receive a copy of the Human Resource Policy that states that employees have the right to review their Human Resource File. Human Resource Director will verify policy sign off at the time of hire on all staff. |
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 shall 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 on May 1, 2008, the facility failed to obtain an informed and voluntary consent from the client in one of nine client records reviewed, #8. The specific information to be disclosed on the consent to release information form to Keystone Health Plan exceeded that allowed under the limitations imposed by 4 Pa. Code 255.5. The specific information to be disclosed included aftercare plans.
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Plan of Correction
In-service training will be conducted for all outpatient staff on the protocol for completion of informed and voluntary consents on June 4, 2008.
Training and implementation of this information will be ensured by the Program Director. Program Director and Site Manager will ensure compliance by monitoring this in the monthly Performance Improvement process via chart audits.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on May 1, 2008, the facility failed to document complete psychosocial evaluations in three of three client records reviewed, #1, 2 and 3. The evaluations were a repeat of historical data and did not include a clinical assessment of the client's assets/strengths, support systems and negative factors that may inhibit treatment.
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Plan of Correction
In-service training on June 12, 2008, to be conducted by the Program Director, will include the regulation that assessments need to be strenght-based as opposed to historical in nature. Implementation of this information will be ensured by the Program Director. Program Director and Site Manager will ensure compliance by monitoring this in the monthly Performance Improvement process via chart audits. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records on May 1, 2008, the facility failed to document a complete treatment plan update in three of three client records reviewed, #1, 2 and 3. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the treatment plan. Additionally, the treatment plan updates were not dated so it could not be determined if they were completed within the required timeframe.
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Plan of Correction
An treatment planning in-service training on June 26, 2008 will include time frames for completion of treatment plans and treatment plan updates. This training will be conducted by the Program Director. The importance of summarizing the status of the treatment objectives will be reviewed and reinforced according to regulation. Implementation of this information will be ensured by the Program Director. Program Director and Site Manager will ensure compliance by monitoring this in the monthly Performance Improvement process via chart audits. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 on May 1, 2008, the facility failed to document that counseling services were provided according to the treatment plan in one of three client records reviewed, #3. The treatment plan prescribed one individual session a month. Only two individual sessions were documented during six months of treatment.
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Plan of Correction
The in-service training for June 26, 2008 will include the requirement for individual session for the outpatient, intensive outpatient and the partial hospitalization levels of care. The importance of documentation on the service record will also be included. The training will be conducted by the Program Director.Implementation of this information will be ensured by the Program Director. Program Director and Site Manager will ensure compliance by monitoring this in the monthly Performance Improvement process via chart audits. |
709.93(a)(3) LICENSURE Client records
709.93. 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:
(3) Record of services provided.
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Observations
Based on a review of client records on May 1, 2008, the facility failed to document a complete record of service in two of three client records reviewed, #2 and 3. The records of service did not document the type of service the client received.
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Plan of Correction
In-service training on requirements for individual counseling will be covered on June 12, 2008 for all outpatient staff. This training will be conducted by the Program Director. The three levels of care from outpatient to partial hospitalization will be reviewed. Documentation on the service record will also be attended to at this training. Implementation of this information will be ensured by the Program Director. Program Director and Site Manager will ensure compliance by monitoring this in the monthly Performance Improvement process via chart audits. |
709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records on May 1, 2008, the facility failed to document an aftercare plan in one of two records reviewed, #4
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Plan of Correction
The aftercare requirements and follow up procedure will be the subject of the in-service training scheduled for June 26, 2008, conducted by the Program Director. All outpatient staff will be instructed on how to reach out to clients who have completed the program or who have been referred or triaged to another facility. Implementation of this information will be ensured by the Program Director.Program Director and Site Manager will ensure compliance by monitoring this in the monthly Performance Improvement process via chart audits. |
709.93(a)(11) LICENSURE Client records
709.93. 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 on May 1, 2008, the facility failed to document follow-up information in three of three client records reviewed, #4, 5 and 6. Follow up information was missing.
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Plan of Correction
Procedure for follow up to next level of care or status after discharge will be the topic of an in-service training for all staff to review aftercare and follow-up procedures. This training will be conducted on 6/26/2008 by the Program Director. Implementation of this information will be ensured by the Program Director. Program Director and Site Manager will ensure compliance by monitoring this in the monthly Performance Improvement process via chart audits. |