INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 8, 2022 through February 9, 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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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 personnel records, the facility failed to ensure that clinical supervisors, who have not functioned for 2 years as a supervisor in the provision of clinical services prior to hiring, completed a Department-approved core curriculum in clinical supervision in one of one applicable personnel record reviewed.
Employee #9 was hired as a clinical supervisor on February 14, 2021 and did not have clinical supervision experience prior to being hired. There was no documentation of the clinical supervision core curriculum training on file at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The identified Clinical Supervisor was registered for a DDAP facilitated and approved core curriculum training. Due to the distance, limited offerings and COVID-19; the registered training will occur and be complete by June 10th, 2022. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on February 8, 2021, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The men's community bathroom, located in the New Wing first floor of the detox area, had what appeared to be mildew or mold on the ceiling. Additionally, there was observable dirt at the corner of the vanity.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately following physical plant inspection of the bathroom during the course of survey on 2/8/2022, the bathroom was deep cleaned as well as painted. During re-inspection the following day, 2/9/2022, the bathroom was reported to have been satisfactory with regulation met prior to survey exit.
Ongoing, the Director of Plant Operations will monitor and inspect each patient bathroom daily for compliance of the cleaning and sanitizing procedures in housekeeping. The compliance of the standards will be reported monthly to the Environment of Care 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 fifteen client records reviewed.
Client #8 was admitted to the rehabilitation level of care on October 3, 2021 and was discharged on November 3, 2021. A blank release of information form was signed and dated by the client on November 3, 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 Clinical Services and The Director of Quality Assurance to all clinical staff on the prohibited use of blank/signed Release of Information documents 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.
Ongoing, Director of Clinical Services or designee will monitor through monthly chart audits to ensure full and proper completion of all Release of Information documents as per policy. Compliance data of the audits will be reported monthly to 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 was offered to the client in one of fifteen client records reviewed.
Client #8 was admitted to the rehabilitation level of care on October 3, 2021 and was discharged on November 3, 2021. A blank release of information form was signed and dated by the client on November 3, 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
Director of Clinical Services and Director of Quality Assurance will re-educate and re-train all clinical staff to fully fill out forms per policy and state standards by 3/2/2022.
Ongoing, Director of Clinical Services and Director of Quality Assurance will monitor through monthly audits of charts ensuring the compliance for releases of information being fully filled out. Compliance of the audits will be reported monthly within the Performance Improvement Committee.
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709.34 (c) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
Based on an administrative review of the facility's unusual incident reports, the facility failed to file a written unusual incident report with the Department within 3 business days following an outbreak of a contagious disease requiring CDC notification.
There were six incidents that occurred on September 1, 2021, but all incidents were not reported to the Department until September 7, 2021.
There was one incident that occurred September 13, 2021 but was not reported to the Department until September 18, 2021.
There was one incident that occurred on December 25, 2021, three incidents that occurred on December 27, 2021, one incident that occurred on December 28, 2021, six incidents that occurred on December 29, 2021, and one incident that occurred on December 30, 2021, but all incidents were not reported to the Department until January 5, 2022.
There was one incident that occurred on January 6, 2022, one incident that occurred on January 8, 2022, one incident that occurred on January 9, 2022, three incidents that occurred on January 10, 2022, one incident that occurred on January 20, 2022, one incident that occurred on January 21, 2022, and one incident that occurred on January 22, 2022, but all incidents were not reported to the Department until January 27, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/11/2022, The Director of Quality Assurance reviewed the facility policy regarding the reporting of unusual incidents to confirm the policy aligned with state requirements.
Facility Director was re-educated and re-trained on reporting of the unusual incidents through the online portal within the required 3 business days on 2/11/2022.
Timely reporting per facility policy continues to be monitored monthly to ensure continued compliance. For reporting that does not meet timely requirements per facility policy, immediate action will be taken up to and including disciplinary action. Timely reporting data and compliance rates will be reported monthly to Performance Improvement Committee for a period of 4 months for tracking, trending and to assure compliance with policy is met.
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