INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 1, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, UPMC Western Behavioral Health of the Alleghenies 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a counselor on December 18, 2022, and was due to have the communicable disease trainings no later than December 18, 2023. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor and the out of compliance clinician will log on to the DDAP Training Portal (TMS) once per week starting on 4/11/24 during individual supervision to determine if the TB/STD training is available either through virtual learning or through in-person learning within a 100-mile radius from employment site. For future new hires, the supervisor will review the training log one time per month with the new hire during individual supervision to ensure that training requirements are being completed as mandated by DDAP. |
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 the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in one out of eleven applicable client records reviewed.
Client #3 was admitted on September 21, 2023, and discharged on September 21, 2023. A release of information form for legal counsel dated September 21, 2023, did not have documentation that the client was offered a copy of the consent form.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will e-educate clinicians to include the necessity for checking whether the client received or refused a copy of the release demonstrating appropriate consent. Education will be conducted on 5/8/24 during the weekly staff meeting. The clinical supervisor will monitor releases through a monthly chart audit for three months and if percentage falls below 90%, individual disciplinary action will be taken. Three charts will be selected per clinician per month. |
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 the review of outpatient client records, the facility failed to document a complete psychosocial evaluation in three out of seven applicable records.
Client #8 was admitted on September 19, 2023, and was discharged November 16, 2023. The clinical summary, completed on September 19, 2023, did not contain any clinical impressions or assessments.
Client #9 was admitted on July 26, 2023, and was discharged on September 1, 2023. The clinical summary, completed on July 26, 2023, did not contain any clinical impressions or assessments.
Client #10 was admitted on July 27, 2023 and was discharged on October 2, 2023. . The clinical summary, completed on July 27, 2023, did not contain any clinical impressions or assessments.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will provide a training to staff on how to write a clinical summary written in a DAP format ? providing data, assessment (clinical judgement), and a preliminary plan for possible treatment related goals. This training will be conducted on 5/22/24 during the weekly staff meeting. The clinical supervisor will monitor clinical impressions when signing each assessment for the next three months. The clinical supervisor will return any assessment to the clinician if the clinical summary does not meet criteria so that it can be corrected. If the clinician appears to have continued issues with clinical assessments, individual education will be provided during weekly individual supervision until the issue is resolved. |
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 outpatient client records, the facility failed to document a follow-up contact within guidelines established by the facility's policy and procedures manual in two out of three applicable records reviewed. The facility's policy and procedures manual states that follow-up contacts will occur within six weeks of discharge.
Client #10 was admitted on July 27, 2023, and was discharged on October 2, 2023. The follow-up contact was due no later than November 13, 2023; however, there was no follow-up contact documented in the client record.
Client #13 was admitted June 14, 2023 and was discharged on October 23, 2023. The follow-up contact was due no later than December 4, 2023; however, there was no follow-up contact documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The administrative assistant will send the follow-up letters immediately upon processing the discharge paperwork which is to be processed within six days of the discharge. The clinical supervisor will monitor aftercare letters through a monthly chart audit for three months and if percentage falls below 90%, individual disciplinary action will be taken. One chart will be selected per clinician per month. |