INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10-11, 2014 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:
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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 a personnel record, the facility failed to ensure that clinical supervisors who have not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision.
The findings include:
One personnel record was reviewed for documentation that a core curriculum in clinical supervision was completed for a clinical supervisor who has not functioned for 2 years as a supervisor in the provision of clinical services on March 10, 2014. The facility failed to ensure that a clinical supervisor completed a core curriculum in clinical supervision in one of one personnel record reviewed, specifically, personnel record #3.
Employee # 3 was hired on November 19, 2012 and promoted to the position of clinical supervisor on July 14, 2013. Based on employee # 3's resume, employee #3 does not have experience functioning as a supervisor in the provision of clinical services. Therefore, employee #3 was due to complete a core curriculum in clinical supervision upon employment in her current position.
As of the date of inspection, there was no documentation of a core curriculum in clinical supervision. Per an interview with the human resources director, employee #3 is scheduled to receive this training on June 9, 2014. The project was previously cited for this deficiency on April 24, 2013.
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Plan of Correction
All new clinical supervisors who have not functioned for two years as a supervisor in the provision of clinical services will attend the core curriculum clinical supervision training at the next offered session, no longer than six months after date of hire or date of promotion. Compliance will be monitored by HR Director. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on the review of inpatient client records, the facility failed to document a complete client record to include follow-ups.
The findings include:
Eight inpatient client records were on March 10, 2014; four of these records were of discharged clients and were reviewed for follow-up documentation. The facility failed to document follow-ups in four out of four discharged inpatient client records, specifically records # 1, 2, 3, and 4.
Client #1 was discharged on November 29, 2013. As of the date of inspection there was no documentation of a follow-up for client #1.
Client #2 was discharged on January 23, 2014. As of the date of inspection there was no documentation of a follow-up for client #2.
Client #3 was discharged on October 13, 2013. As of the date of inspection there was no documentation of a follow-up for client #3.
Client #4 was discharged on January 4, 2014. As of the date of inspection there was no documentation of a follow-up for client #4.
The findings were reviewed and confirmed with the clinical director and project director.
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Plan of Correction
Follow-up calls to outpatient provider will be made within seven days of date of discharge. Results of call will be documented in each client's medical record. All clinical staff were retrained by Director of Clinical Services on follow-up process and time frames during staff meetings on April 4, 2014 and April 9, 2014. Compliance will be monitored via monthly closed chart audits conducted by Program Coordinator. Results will be reported monthly to PI Committee. |