INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 16, 2015 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.
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Plan of Correction
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to adhere to the limitations imposed under 4 Pa. Code 255.5 in six out of ten records.
The findings include:
4 Pa. Code states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Ten client records were reviewed on December 14-17, 2015. The facility released information that exceeded the limitations imposed under 4 Pa. Code 255.5 in client record # 1, 2, 5, 8, 9 and 10.
Client #1 - Consent to release form dated August 14, 2015 for an insurance company, allowed for the release of the following documents: aftercare appointment
Client #2 - Consent to release form dated July 22, 2015 for an insurance company, allowed for the release of the following documents: aftercare appointment
Client #5 - Consent to release form dated July 28, 2015 for a government agency, allowed for the release of the following documents: aftercare appointment
Client #8 - Consent to release forms dated July 21, 2015 for a government agency, insurance company and probation officer allowed for the release of the following documents: aftercare appointments and demographic information
Client #9 - Consent to release form dated April 23, 2015 for insurance company allowed for the release of the following documents: aftercare appointments
Client #10- Consent to release form dated September 17, 2015 for a government agency, allowed for the release of the following documents: demographic information
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be retrained during the February 29 staff meeting regarding the standards and policies relevant to the accurate and thorough completion of Consents to release, including specific information that is allowed to be released per PA. Code 255.5.
Staff will also be retrained on the need to document specific details when documenting 'Other' on a release under 'The Purpose Of This Disclosure Is' section.
All Consents noted in the Observations section involving current active clients will be corrected by March 2, 2016 by the Clinical Coordinator and clinical staff. Consents to release will be audited on a monthly basis for accuracy and completion by Key Recovery's Clinical Coordinator. Audit results will be submitted by the Program Director to the Performance improvement Committee on a monthly basis. |
709.28(e)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(e) Where consent is not required, the project personnel shall:
(2) Inform the client, as readily as possible, that the information was disclosed, for what purposes and to whom.
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Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consents in two of ten records reviewed.
The findings include:
Ten client records were reviewed on December 16-17, 2015. All were reviewed for informed and voluntary consent forms. The facility failed to document if the client was offered a copy of the consents.
Client #1 - Consent to release dated August 14, 2015 for the parole officer and insurance company failed to document if client accepted or rejected a copy of consents.
Client #2 - Consent to release dated July 22, 2015 for a friend, project failed to document if client accepted or rejected a copy of consents.
Client #8- Consent to release dated July 21, 2015 for a project failed to document information if client accepted or rejected a copy of consents and the purpose of this disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff re-training was held on January 22, 2016 to review the standards and policies regarding the accurate and complete completion of Consents to release, including documentation of whether a client accepted or rejected a copy of the release.
All consents of active clients will be corrected by Key Recovery's Clinical Coordinator and assigned therapist by March 2, 2016.
Consents to release will be audited on a monthly basis for accuarcy and completion by Key Recovery's Clinical Coordinator. Audit results will be submitted by the Program Director to the Performance improvement Committee on a monthly basis. |
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, the facility failed to complete psychosocial evaluations in three of ten client records.
The findings include:
Ten client records were reviewed on December 16 and 17, 2015. Psychosocial evaluations were reviewed in all records reviewed. The facility failed to complete a psychosocial evaluation in client records, #8, 9 and 10.
The psychosocial evaluations were disjointed with listed responses and client reported comments rather than a clinical assessment of the when it came to the client composite picture, clients problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, clients attitude toward treatment and the counselors impression/impression of the client in client records #8, 9 and 10.
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Plan of Correction
A staff re-training is scheduled for February 8, 2016 to review the proper and comprehensive completion of psychosocial evaluations to include a composite clinical assessment and summary of the client's presentation. Psychosocial evaluations will be audited on a monthly basis for accuarcy and completion by Key Recovery's Clinical Coordinator. Audit results will be submitted by the Program Director to the Performance improvement Committee on a monthly basis. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to display the facility's hours of operation that can be accessed by the general public in case of an emergency.
The findings include:
A physical plant inspection was conducted on December 16, 2015. The facility failed to display the facility ' s hours of operation.
An interview with the facility director on October 18, 2012 confirmed the findings.
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Plan of Correction
Key Recovery's Hours of Operation and Emergency Telephone Number were posted on the office suite doors of the building, meeting the standard that this information was conspicuously displayed for the benefit of the general public.
This was completed on 12/16/2015. The Program Director placed the hours of operation on the suite door. The Program Director will ensure on a daily basis that the Hours of Operation and the Emergency Telephone Number remain posted for the benefit of the general public. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to document supervision during the first six months in one of nine personnel records.
The findings include:
The personnel record of employee #2, the facility's clinical supervisor, was reviewed on December 14, 2015.
Employee # 2 was promoted as a clinical supervisor at the project on December 28, 2014. Supervison notes were documented on May - October 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For new supervisors, Key Recovery will document supervision notes with the Program Director for the initial six months after the employee has been hired/promted to a clinical superviser position. |