INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on April 30, 2012, to May 2, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, UHS Recovery Foundation 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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704.7(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 the review of personnel records and a review of the staffing requirements facility summary report, the facility failed to ensure that each counselor met the qualifications for the position in two of fourteen records reviewed.
The findings include:
Fourteen personnel records and the facility staffing requirement summary report were reviewed on April 30, 2012 to May 1, 2012. The facility failed to provide documentation of counselor qualifications in personnel records # 9 and 11.
In personnel record # 9, the counselor did not meet the qualifications for the position of counselor based on a Bachelor of Arts degree in Criminal Justice without documentation of one year of clinical experience.
In personnel record # 11, the counselor did not meet the qualifications for the position of counselor based on a Bachelor of Arts degree in Psychology without documentation of one year of clinical experience.
The findings were reviewed with the Project Director and facility staff on May 2, 2012.
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Plan of Correction
Human Resource Director will insure that the two identified Counselors will have their positions changed from Counselor to Counselor Aide until they both meet the one year of required clinical experience effective 5/18/12. Affected employees have been given new job descriptions which have been signed by employee and supervisor to reflect change. Human Resource Director and Facility Director will review credentials of all prospective staff candidates with regard to DOH Staffing Qualifications (CH. 704) to assure proper classification and compliance. Human Resource Director will perform quarterly personnel file audits to assure compliance. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document an annual evaluation of the overall training plan per the facility policy.
The findings include:
The policy and procedure manual was reviewed on April 30, 2012. Facility policy required that an annual evaluation of the training plan be completed by the Human Resources director and submitted to the Board of Governors by January 15th of each year. The facility training year is from January through December. The facility documented that the annual evaluation of the 2011 training plan was completed by the Human Resources director and presented to the Board of Governors in February 2012.
The findings were reviewed with the Project Director and the Human Resources director on May 2, 2012, and were not disputed.
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Plan of Correction
Human Resources Director will insure that the annual evaluation of the training plan will be completed and presented to the Board of Governors by January 15th of every year per policy going forward. |
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 the staffing requirements facility summary report, the facility failed to provide documentation of HIV/AIDS and TB/STD training for seven of seventy-nine personnel records.
The findings include:
The facility staffing requirement summary report were reviewed on April 30, 2012 to May 1, 2012. Seventy-nine personnel records were required to have documentation of HIV/AIDS and TB/STD training. The facility failed to provide documentation of the required HIV/AIDS and TB/STD training for personnel records # 8, 13, 15, 16, 17, 18 and 19.
Employee # 8 is a counselor and was hired on 2/7/2011. HIV/AIDS and TB/STD training was due to be completed no later than 2/7/2012. The facility failed to ensure that the HIV/AIDS and TB/STD training were completed within one year of hire. The employee did not receive HIV/AIDS training until 3/29/2012 and the TB/STD training until 3/1/2012.
Employee # 13 is a counselor and was hired on 1/3/2011. TB/STD training was due to be completed no later than 1/3/2012. The facility failed to ensure that the TB/STD training was completed within one year of hire. The employee did not receive the TB/STD training until 3/1/2012.
Employee # 15 is a counselor and was hired on 10/19/2010. HIV/AIDS and TB/STD training was due to be completed no later than 10/19/2011. The facility failed to ensure that the HIV/AIDS and TB/STD training were completed within one year of hire. The employee did not receive HIV/AIDS training until 3/29/2012 and the TB/STD training until 3/1/2012.
Employee # 16 is a counselor and was hired on 2/23/2011. HIV/AIDS and TB/STD training was due to be completed no later than 2/23/2012. The facility failed to ensure that the HIV/AIDS and TB/STD training were completed within one year of hire. The employee did not receive HIV/AIDS training until 3/29/2012 and the TB/STD training until 3/1/2012.
Employee # 17 is a counselor and was hired on 2/15/2011. HIV/AIDS training was due to be completed no later than 2/15/2012. The facility failed to ensure that the HIV/AIDS training was completed within one year of hire. The employee did not receive HIV/AIDS training until 3/29/2012.
Employee # 18 is a cook and was hired on 9/17/2008. HIV/AIDS and TB/STD training was due to be completed no later than 9/17/2010. The facility failed to ensure that the HIV/AIDS and TB/STD training were completed within two years of hire. The employee did not receive HIV/AIDS training until 2/24/2011 and the TB/STD training until 3/14/2011.
Employee # 19 is an admissions counselor and was hired on 2/10/2010. TB/STD training was due to be completed no later than 2/10/2012. The facility failed to ensure that the TB/STD training was completed within two years of hire. The employee did not receive the TB/STD training until 3/1/2012.
The findings were reviewed with the Project Director on 5/2/2012 and not disputed.
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Plan of Correction
Human Resources Director will insure that the all staff will receive required HIV/AIDS and TB/STD training within the required time frame for position for which they were hired effective May 24, 2012. Human Resources Director will perform quarterly audits of personnel files to assure compliance. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of personnel records, the facility failed to document written job descriptions which contained the employee's and supervisor's dated signatures in two of six personnel records.
The findings include:
Seven personnel records were reviewed on April 30, 2012 to May 1, 2012. Six personnel records were reviewed for documentation of a signed job description. The facility did not document a signed job description in personnel records # 4 and 5.
Personnel record # 4 pertained to a counselor with a documented hire date of 3/14/2012. An initial job description was signed by the employee on 3/14/2012. There was no documented signature of the supervisor.
Personnel record # 5 pertained to a counselor with a documented hire date of 12/26/2011. An initial job description was signed by the employee on 12/19/2011. There was no documented signature of the supervisor.
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Plan of Correction
Human Resources Director will insure that all written job descriptions be revised and contain the employee's signature as well as supervisor's dated signature when hired as well as yearly, effective May 24, 2012. Human Resources Director will perform quarterly audits of personnel files to assure compliance. |
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 the review of patient records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in five of five patient records reviewed.
The findings included:
Eight patient records were reviewed May 2, 2012. Five records were reviewed regarding release of information documentation. The facility failed to ensure that an informed and voluntary consent to release information was obtained in five patient records reviewed, # 4, 5, 6, 7, and 8.
A review of patient record # 4 revealed that a consent to release information to a funding source on April 24, 2012, was not signed by the patient. The patient did not sign a release prior to releasing information to the funding entity. A consent to release information to a pharmacy was signed on April 24, 2012. The patient signed for the release of presence in treatment, program description, progress in treatment and discharge date and type. The purpose identified on the release was for medication dispensation. The information released was beyond the scope of the information identified.
A review of patient record # 5 revealed that a consent to release information to a pharmacy was signed on April 24, 2012. The patient signed the consent granting permission for the release of information pertaining to the presence of treatment, program description, progress in treatment and discharge date and type. The purpose identified on the release was for medication dispensation. The information released was beyond the scope of the information identified.
A review of patient record # 6 revealed that a consent to release information to a pharmacy was signed on April 29, 2012. The patient signed the consent granting permission for the release of information pertaining to the presence of treatment, program description, progress in treatment and discharge date and type. The purpose identified on the release was for medication dispensation. The information released was beyond the scope of the information identified.
A review of patient record # 7 revealed that information was released to a funding source on April 12, 2012. The release of information was signed by the patient on April 15, 2012.. The patient did not sign a release prior to releasing information for the funding entity. The patient signed the consent granting permission for the release of information pertaining to the presence of treatment, program description, progress in treatment and discharge date and type. The purpose identified on the release was for medication dispensation. The information released was beyond the scope of the information identified.
A review of patient record # 8 revealed that a consent to release information to a pharmacy was signed on April 11, 2012. The patient signed the consent granting permission for the release of information pertaining to the presence of treatment, program description, progress in treatment and discharge date and type. The purpose identified on the release was for medication dispensation. The information released was beyond the scope of the information identified.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
The Pharmacy Consent to Release Information has been completely revised as of May 21, 2012. The information released is limited to presence in treatment, insurance information, medication allergies/reactions and medication orders. All other information has been eliminated from the release.
The Director of Admissions conducted a training for all admission staff on confidentiality/client releases on May 21, 2012. The necessity of having clients sign all pertinent releases was included in the training. Compliance will be monitored through daily chart reviews by an admission counselor.
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709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on the review of patient records, the facility failed to ensure the physician or certified registered nurse practitioner signed the verbal order within 24 hours as required by the regulations in one of one records reviewed.
The findings include:
Eight patient records were reviewed May 2, 2012. One record contained documentation of a physician's verbal order. A verbal order was created on 4/26/2012 by a physician. The order was signed by the certified registered nurse practitioner. A verbal order is to be signed by the prescribing physician. The prescribing physician had not signed off on the order at the time of the review.
The Director of Nursing confirmed this finding. This is a repeat citation from the January 3, 2012 and the January 20, 2011 buprenorphine monitoring inspections.
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Plan of Correction
Nurse receiving verbal order will fax via secure fax all verbal orders/ telephone verbal orders to the author of the verbal order. The physician who gave the verbal order will electronically sign the order and secure fax back to nursing within 24 hours.
The signed returned copy will be placed on top of the original order, stapled together and placed in the chart in the physician order section by the receiving nurse. All nursing staff and physicians will be trained by DON in new procedure and procedure will be implemented by 6/01/12. This process will be monitored by Director of Nursing and will be audited via 24 hour chart checks for compliance. Results will be reported at monthly Performance Improvement meeting.
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709.62(c)(2)(i) LICENSURE Orientation Proj policies
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(i) Project policies, which include the following:
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Observations
Based on a review of patient records, the facility failed to document patient orientation in one of two patient records.
The findings include:
Three patient records were reviewed on May 2, 2012. Two patient records were reviewed for documentation of patient orientation. The facility did not document patient orientation in patient record # 6
Patient # 6 was admitted on 4/29/2012. A review of the documentation provided at the time of the inspection revealed that the patient's orientation to the facility could not be confirmed.
The findings were reviewed with the facility director and not disputed.
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Plan of Correction
The orientation process has been revised to incorporate a sign-off form for each client to acknowledge receiving orientation. Clinical Director conducted trainings for all clinical staff on all shifts. Trainings were held on May 24, 2012 and May 30, 2012. All clinical staff was educated on the use of this new form. Compliance will be monitored through regular monthly open chart audits conducted by the Clinical Director and regular monthly closed chart audits conducted by the Program Coordinator. |
709.63(a)(5) LICENSURE Record of Services
709.63. 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:
(5) Record of services provided.
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Observations
Based on a review of patient records, the facility failed to document a complete record of services provided in two of two records reviewed.
The findings include:
Three patient records were reviewed on May 2, 2012. Two patient records were reviewed for documentation of a record of services provided by the facility. The facility did not document a complete record of services provided in patient records # 5 and 6.
Patient # 5 was admitted on 4/24/2012. The record of services failed to document individual sessions on 4/25/2012 and 4/30/2012.
Patient # 6 was admitted on 4/29/2012. The record of services failed to document an individual session on 4/30/2012 and documented an individual session as a family session on 5/1/2012.
The findings were reviewed with the facility director and not disputed.
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Plan of Correction
Clinical Director conducted trainings for all clinical staff on all shifts. Trainings were held on May 24, 2012 and May 30, 2012. Proper completion of record of services was reviewed and staff was instructed that all services provided must be documented. Compliance will be monitored through regular monthly open chart audits conducted by the Clinical Director and regular monthly closed chart audits conducted by the Program Coordinator. |
709.52(a)(3) LICENSURE Support service type
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on the review of patient records, the facility failed to document support services in the individual treatment and rehabilitation plan in three of three patient records.
The findings include:
Five patient records were reviewed on May 2, 2012. Three records were reviewed for support services in the individual treatment and rehabilitation plan. The facility did not document support services in the individual treatment and rehabilitation plan in records # 4, 7 and 8.
Patient # 4 was admitted on 4/24/2012. An individual treatment and rehabilitation plan was signed by the patient on 4/26/2012. The area for identified support services remained blank.
Patient # 7 was admitted on 4/15/2012. An individual treatment and rehabilitation plan was signed by the patient on 4/17/2012. The area for identified support services remained blank.
Patient # 8 was admitted on 4/11/2012. An individual treatment and rehabilitation plan was signed by the patient on 4/13/2012. The area for identified support services remained blank.
The findings were reviewed with the facility director and not disputed.
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Plan of Correction
Clinical Director conducted a training for all clinical staff who prepare treatment plans. Training was held on May 24, 2012. Staff was instructed to document support services for each client on each treatment plan. Staff was further instructed that if no support services were needed to document that as well. Compliance will be monitored through regular monthly open chart audits conducted by the Clinical Director and regular monthly closed chart audits conducted by the Program Coordinator. |