INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 25, 2013 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 in one of one personnel record reviewed.
The findings include:
From April 23, 2013 to April 24, 2013, 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. 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 is a clinical supervisor that is an existing employee that was hired in her current position on August 26, 2012. Based on employee # 3's resume, employee # 3 has experience as a supervisor. However, 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. However, personnel record # 3 did not include documentation that employee # 3 completed a core curriculum in clinical supervision as of April 25, 2013.
The findings were confirmed during an interview with the human resource director on April 24, 2013 at approximately 1:00 P.M.
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Plan of Correction
Employee #3 has registered for a clinical supervision training scheduled for June 10-14, 2013. Proof of registration was submitted on April 25, 2013 during the licensing inspection.
Upon conclusion of the training, employee #3 will submit documentation of attendance and successful completion of the training to the Facility Director and Human Resources Director.
Moving forward, Human Resources Director will complete a quarterly personnel file audit to ensure that all new supervsiors will have completed the required core curriculum for clinical supervsiors training within six months of starting the position. Human Resources Director will collaborate with Fcility Director to ensure all supervsiors have attended required training. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of client records, the facility failed to document an initial individual training plan for a newly hired employee within 30 days from the employee's date of hire in three of four personnel records reviewed. Also, the facility failed to document an individual training plan that includes potential resources for training which meet the requirements for the employee's position and which relate to the employee's skill level and interest in six of nine personnel records reviewed.
The findings include:
From April 23, 2013 to April 24, 2013, nine personnel records requiring documentation of an individual training plan were reviewed. The facility did not document an individual training plan that included potential resources for employees in six of nine records reviewed, specifically, personnel records # 1, 2, 3, 4, 8, and 9. Also, the facility did not document an initial individual training plan for a newly hired employee within 30 days from the employee's date of hire in three of four records reviewed, specifically, personnel records # 4, 5, and 6.
Employee # 1 is the project director and was hired for his current position August 1, 2005. An individual training plan was completed on November 27, 2012; however, the individual training plan did not include potential resources for employee # 1.
Employee # 2 is the facility director and was hired for his current position March 27, 2011. An individual training plan was completed on December 19, 2012; however, the individual training plan did not include potential resources for employee # 2.
Employee # 3 is the clinical supervisors and was hired for her current position August 26, 2012. An individual training plan was completed on December 17, 2012; however, the individual training plan did not include potential resources for employee # 3.
Employee # 4 is counselor and was hired on September 5, 2012. An initial individual training plan was due October 5, 2012. The initial individual training plan was completed but did not include a date of completion. Also, the annual individual training plan was completed on December 20, 2012; however, the individual training plan did not include potential resources for employee # 4.
Employee # 5 is a counselor and was hired on December 26, 2012. An initial individual training plan was due January 25, 2013. The initial individual training plan was completed but did not include a date of completion.
Employee # 6 is a counselor and was hired on December 26, 2012. An initial individual training plan was due January 25, 2013. The initial individual training plan was completed but did not include a date of completion.
Employee # 8 is a counselor and was hired November 3, 2011. An individual training plan was completed on December 19, 2012; however, the individual training plan did not include potential resources for employee # 8.
Employee # 9 is a counselor and was hired April 3, 2008. An individual training plan was completed on December 19, 2012; however, the individual training plan did not include potential resources for employee # 9.
The findings were confirmed during an interview with the human resource director on April 24, 2013 at approximately 8:30 A.M.
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Plan of Correction
The individual training plans for employee numbers 4,5, and 6 have been amended to include the date of completion effective 5/20/13. Human Resources will ensure that going forward all initial individual training plans for newly hired employees are completed and dated with 30 days of hire. Human Resources Director updated form and added signature and date for employees as well as supervisor to sign off effective 5/20/13. Human Resources Director will complete monthly audits to ensure compliance.
The individual training plans for employee numbers 1, 2, 3, 4, 8, & 9 have been amended to include potential resources for training effective 5/20/13.
Human Resources Director has revised individual training plans to include potential resources for training which meet the requirement for the employee's position as well as to the employee's skill level and interest effective 5/20/13.
Human Resources Director will complete personnel file audits to ensure compliance.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan update and/or subsequent individual treatment and rehabilitation plan update that included an assessment of the client's progress in six of seven client records reviewed. Also, the facility failed to document an individual treatment rehabilitation plan update in two of nine client records reviewed.
The findings include:
The facility's policy titled: "Clinical Services/Medical Records," states:
"Treatment Care Plan Update required within 30 days PH/IOP; 60 days OP."
On April 25, 2013, nine client records requiring documentation of an individual treatment and rehabilitation plan update were reviewed. The facility did not document an individual treatment and rehabilitation plan update and/or subsequent individual treatment and rehabilitation plan update that included an assessment of the client's progress in six of seven client records reviewed, specifically, client records # 1, 2, 3, 4, 6, and 7. The facility also did not document an individual treatment rehabilitation plan update in two of nine client records reviewed, specifically, client records # 5 and 8.
Client # 1 was admitted November 20, 2012. The individual treatment and rehabilitation plan was completed November 23, 2012 and the individual treatment plan update was completed December 23, 2012. The subsequent individual treatment plan updates were completed January 21, 2013; February 21, 2013; and March 21, 2013. However, the individual treatment and rehabilitation plan update and subsequent individual treatment plan updates did not include an assessment of the client's progress as of April 25, 2013.
Client # 2 was admitted July 11, 2012. The individual treatment and rehabilitation plan was completed July 18, 2012 and the individual treatment plan update was completed August 20, 2012. The subsequent individual treatment plan updates were completed September 20, 2012; February 20, 2013; and April 20, 2013. However, the individual treatment and rehabilitation plan update and subsequent individual treatment plan updates did not include an assessment of the client's progress as of April 25, 2013.
Client # 3 was admitted July 30, 2012. The individual treatment and rehabilitation plan was completed August 6, 2012 and the individual treatment plan update was completed September 2012. The subsequent individual treatment plan updates were completed October 5, 2012; February 1, 2013; and April 1, 2013. However, the individual treatment and rehabilitation plan update and subsequent individual treatment plan updates did not include an assessment of the client's progress as of April 25, 2013.
Client # 4 was admitted January 16, 2013. The individual treatment and rehabilitation plan was completed January 18, 2013 and the individual treatment plan update was completed February 18, 2013. The subsequent individual treatment plan updates were completed March 18, 2013 and April 18, 2013. However, the individual treatment and rehabilitation plan update and subsequent individual treatment plan updates did not include an assessment of the client's progress as of April 25, 2013.
Client # 5 was admitted January 9, 2013. The individual treatment and rehabilitation plan was completed January 6, 2013. The individual treatment and rehabilitation plan update was due February 5, 2013. However, client record # 5 did not include documentation of an individual treatment rehabilitation plan update as of April 25, 2013.
Client # 6 was admitted December 5, 2012. The individual treatment and rehabilitation plan was completed December 11, 2012 and the individual treatment plan update was completed February 5, 2013 but did not include an assessment of the client's progress as of April 25, 2013.
Client # 7 was admitted July 18, 2012 and discharged October 22, 2012. The individual treatment and rehabilitation plan was completed July 18, 2012, the individual treatment plan update was completed August 18, 2012 , and the subsequent individual treatment plan update September 12, 2012. However, the individual treatment and rehabilitation plan update and subsequent individual treatment plan update did not include an assessment of the client's progress as of April 25, 2013.
Client # 8 was admitted October 19, 2012 and discharged January 15, 2013. The individual treatment and rehabilitation plan was completed October 19, 2012. The individual treatment and rehabilitation plan update was due November 18, 2012. However, client record # 8 did not include documentation of an individual treatment rehabilitation plan update as of April 25, 2013.
The findings were confirmed during an interview with the clinical supervisor on April 25, 2013 at approximately 2:30 P.M.
This is a repeat citation. The facility was cited on May 3, 2012 for noncompliance with this standard.
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Plan of Correction
The Individual Treatment and Rehabilitation Plan Update form has been revised to include a section which provides an opportunity to document an assessment in narrative form of the client's progress in working toward the completion of the goals documented on the Individual Treatment and Rehabilitation Plan Update. This revised Individual Treatment and Rehabilitation Plan Update form was reviewed in a recent staff meeting. In client records #1,2,3,4,6,and 7, the treatment care plan updates will be amended by 6/3/2013. For client records #5 and 8, the treatment care plan updates will be completed by 6/03/2013.
30 open medical records and 20 closed medical reciords will be audited each month to ensure compliance. Results of the medical record audits will be reviewed in staff meetings and submitted to the Performance Improvement Committee on a monthly basis. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on an interview with the clinical supervisor and review of client records, the facility failed to comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
The findings include:
The regulation at 55 Pa. Code Part III chapter 1223.52 section (a) subsection 6 (i) - (ii) specifies that "within 15 days following intake, the clinic's supervisory physician shall review and verify each patient's level of care assessment, psychosocial evaluation and initial treatment plan prior to the provision of any treatment beyond the 15th day following intake. The clinic's supervisory physician shall verify the patient's diagnosis. The clinic's supervisory physician shall sign and date the patient's level of care assessment, psychosocial evaluation, treatment plan and diagnosis in the patient's record. Payment will not be made for services provided within or beyond the 15th day following intake, without the clinic's supervisory physician's review and approval of the level of care assessment, psychosocial evaluation, treatment plan and determination of the patient's diagnosis. Sixty days following the date of the initial treatment plan and at the end of every 60-day period during the duration of treatment, the clinic's supervisory physician shall review and update each patient's treatment plan. Each review and update shall be dated, documented and signed in the patient's record by the clinic's supervisory physician."
On April 25, 2012, six client records requiring documentation of a physician's signature on client treatment plans were reviewed. A physician did not sign the individual treatment and rehabilitation plan in six of six records reviewed, specifically, client records # 1, 2, 4, 5, 6, and 7. A physician also did not sign the individual treatment and rehabilitation plan update and/or subsequent individual treatment and rehabilitation plan update in five of five records reviewed, specifically, client records # 1, 2, 4, 6, and 7.
Client # 1 was admitted November 20, 2012. A physician was required to sign the individual treatment and rehabilitation plan, the treatment plan update, and the subsequent treatment plan updates. The individual treatment and rehabilitation plan was completed November 23, 2012 and the treatment plan update was completed December 23, 2012. The subsequent treatment plan updates were completed January 21, 2013; February 21, 2013; and March 21, 2013. However, the individual treatment and rehabilitation plan, the treatment plan update, and subsequent treatment plan updates did not include documentation of a physician's signature as of April 25, 2013.
Client # 2 was admitted July 11, 2012. A physician was required to sign the individual treatment and rehabilitation plan, the treatment plan update, and the subsequent treatment plan updates. The individual treatment and rehabilitation plan was completed July 18, 2012 and the treatment plan update was completed August 20, 2012. The subsequent treatment plan updates were completed September 20, 2012; February 20, 2013; and April 20, 2013. However, the individual treatment and rehabilitation plan, the treatment plan update, and subsequent treatment plan updates did not include documentation of a physician's signature as of April 25, 2013.
Client # 4 was admitted January 16, 2013. A physician was required to sign the individual treatment and rehabilitation plan, the treatment plan update, and the subsequent treatment plan updates. The individual treatment and rehabilitation plan was completed January 18, 2013 and the treatment plan update was completed February 18, 2013. The subsequent treatment plan updates were completed March 18, 2013 and April 18, 2013. However, the individual treatment and rehabilitation plan, the treatment plan update, and subsequent treatment plan updates did not include documentation of a physician's signature as of April 25, 2013.
Client # 5 was admitted January 9, 2013. A physician was required to sign the individual treatment and rehabilitation plan. The individual treatment and rehabilitation plan was completed January 6, 2013 but did not include documentation of a physician's signature as of April 25, 2013.
Client # 6 was admitted December 5, 2012. A physician was required to sign the individual treatment and rehabilitation plan and the treatment plan update. The individual treatment and rehabilitation plan was completed December 11, 2012 and the treatment plan update was completed February 5, 2013. However, the individual treatment and rehabilitation plan and the treatment plan update did not include documentation of a physician's signature as of April 25, 2013.
Client # 7 was admitted July 18, 2012 and discharged October 22, 2012. A physician was required to sign the individual treatment and rehabilitation plan, the treatment plan update, and the subsequent treatment plan updates. The individual treatment and rehabilitation plan was completed July 18, 2012, the treatment plan update was completed August 18, 2012, and the subsequent treatment plan update was completed September 12, 2012. However, the individual treatment and rehabilitation plan, the treatment plan update, and the subsequent treatment plan update did not include documentation of a physician's signature as of April 25, 2013.
The findings were confirmed during an interview with the clinical supervisor and project director on April 25, 2013 at approximately 2:30 P.M.
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Plan of Correction
Within 15 days following intake, Key Recovery's physician will review and verify each patient's level of care assessment, psychosocial evaluation and initial treatment plan. The physician shall verify the patient's diagnosis. The physician will sign and date the patient's level of care assessment, psychosocial evaluation, treatment plan and diagnosis in the patient's medical record. Sixty days following the date of the initial treatment plan and at the end of every 60-day period during the duration of treatment, the physician will review and update each patient's treatment plan. Each review and update will be dated, documented and signed in the patient's record by physician.
For client records #1,2,4,5,6 and 7 the physician will sign the individual treatment and rehabilitation plans by 6/4/2013. For client records #1,2,4,6 and 7 the physician will sign the treatment plan updates and/or subsequent treatment plan updates by 6/4/2013. On a monthly basis, 30 open and 20 closed medical records will be audited by the Clinical Coordinator to ensure compliance with physician signatures. Results will be reported monthly to the Performance Improvement Committee by the Facility Director.
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