INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 21-23, 2009 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 and a plan of correction is due on May 26, 2009.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to document staff feedback for completed training in six of seven personnel records. Findings: Eighteen personnel records were reviewed on April 21, 2009. Documentation of staff feedback from completed training was required in seven personnel records. The facility did not document staff feedback for external trainings in personnel records # 1, 2, 3, 5, 6 and 7.
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Plan of Correction
All staff completing internal and external trainings will complete a feedback form and attach to certificate. Human Resource Director will include the feedback form in the employee's personnel record. No certificates will be accepted without a feedback form.
Due Date: May 21, 2009
Responsible: Kevin Williams, HR Director |
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 personnel, records the facility failed to document an annual individual training plan in fourteen of fifteen personnel records.Findings:Eighteen personnel records were reviewed on April 21, 2009. Documentation of an annual individual training plan was required in fifteen personnel records. The facility did not document a training plan to include potential resources for training in personnel records # 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 17 and 18.Additionally, the facility did not document an annual individual training plan in January, as stated in their policy and procedures manual, for personnel records # 8 and 9.
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Plan of Correction
Human Resource Director will include a list of potential resources to all staff to be included in annual training plans. The Director of Human Resources will ensure that all staff receive an annual training plan. A monthly audit by the Human Resources Director of a sample of personnel files will be conducted to ensure compliance.
Responsible: Director of Human Resources
Due Date: May 21, 2009 and ongoing
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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 personnel records, the facility failed to document a minimum of 6 hours HIV/AIDS training and at least 4 hours of tuberculosis/STD training in one of seven personnel records. Findings:Eighteen personnel records were reviewed on April 21, 2009. 6 hours of HIV/AIDS training and 4 hours of tuberculosis/STD training were required in seven personnel records. The facility did not document 6 hours of HIV/AIDS training and 4 hours of tuberculosis/STD training in personnel record # 6.
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Plan of Correction
Employee #6 will receive mandatory HIV/AIDS and tuberculosis/STD training.
Employee will be removed from schedule if training requirements are not satisfied by July 1, 2009.
Responsible: Kevin Williams, Director of Human Resources
Due Date: July 1, 2009
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on an inspection of the facility ' s physical plant, the facility failed to maintain all freezer temperatures at or below zero degrees Fahrenheit.Findings:A physical plant inspection was conducted on April 22, 2009 at 09:40-11:30. At approximately 11:00 the temperature on the thermometer inside of the kitchen walk-in freezer read 8On April 23, 2009 at approximately 14:00 and again at 14:15 the temperature on the thermometer inside the walk-in freezer read 8
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Plan of Correction
The freezer thermostat was adjusted by the Director of Maintenance. This adjusted the defrost cycle, and the unit is now at or below -5 degrees. The Food Service Coordinator will monitor temperature twice daily and will log temperature. Any variation in temperature will be reported to the Director of Maintenance.
Responsible: Director of Maintenance
Due Date: Immediate |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility ' s fire drill log, the facility failed to document a fire drill during sleeping hours at least once every six months.Findings:The facility ' s fire drill log was reviewed on April 23, 2009. The facility's last documented fire drills during sleeping hours were on 05/07/2008 and 02/20/2009.
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Plan of Correction
The Director of Maintenance will conduct a fire drill during patient sleeping hours. Sleeping hours end at 6:30am.
Responsible: Director of Maintenance
Due Date: This was completed on 5/08/2009 |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on the physical plant inspection, the facility failed to ensure the confidentiality of client records.Findings:The physical plant inspection was conducted on April 22, 2009 between 9:30 and 11:30 am. The facility failed to ensure the confidentiality of client records as the door to the room adjacent to client record storage was open and clients and staff were in an adjoining area outside the open door. The room adjacent to client record storage housed a fax and copy machine which could be viewed by anyone in the adjoining area. The facility director stated that the door is normally kept closed. At the end of the physical plant inspection, the licensing specialists passed by this area and observed that the door was still open and clients were in the adjoining area.
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Plan of Correction
The Confidentiality Policy will be revised by May 30, 2009 to include the directive that the inner chart room door remain closed and locked at all times. Staff was advised of the strict enforcement of this policy at a training session held on April 30, 2009 by the Facility Director. This policy will be monitored on a daily basis by the Facility Director.
Responsible: Facility Director Deborah Voluck
Due Date: 5/30/2009 |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in fifteen of sixteen client records reviewed.Findings:Sixteen client records were reviewed on April 22 and 23, 2009. An informed and voluntary consent was required in sixteen client records. The facility failed to obtain an informed and voluntary consent from the client in fifteen of sixteen client records reviewed. The specific information to be released exceeded Pa Code 255.5 in information to be released to funding sources in client records #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16. The information to be released included "aftercare appointments". The specific information to be released exceeded Pa Code 255. 5 in information to be released to probation officers in client records #5, 11, 13 and 15. The information to be released included "aftercare appointments".
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Plan of Correction
The Project Manager completed a new Release of Information Form on April 23, 2009 and it has been in use since that date. Clinical staff was trained on what specific information can and cannot be released on April 30, 2009 by the Facility Director. Compliance will be monitored during regular clinical supervision sessions by Clinical Supervisor.
Responsible: Facilty Director Deborah Voluck
Due Date: 4/23/2009 |
709.30(3) LICENSURE Client Rights
709.30. Client rights.
(3) A client has the right to inspect his own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
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Observations
Based on a review of client records and the Patient Handbook Bill of Rights, the facility failed to ensure that the client is aware that he has the right to inspect his own records in sixteen of sixteen client records reviewed.Findings:Sixteen client records were reviewed on April 22 and 23, 2009. Disclosure to the client of his right to review his own records was required in sixteen client records. The Patient Bill of Rights, which was signed by each client in client records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16, stated that the client could review his own records only with the "supervision/approval of the case manager, physician and medical director".
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Plan of Correction
The Facility Director revised the section of the "Patient Bill of Rights" to reflect that clients have the right to review his/her own medical records. The phrase "only with the supervision/approval of the case manager, physician and medical director" has been deleted. This was completed on May 4, 2009.
Responsible: Facility Director Deborah Voluck
Due Date: Completed on 5/04/2009 |
709.63(a)(3) LICENSURE Progress notes
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:
(3) Progress notes.
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Observations
Based on a review of client records, the facility failed to document a progress note after each significant client contact in five of six client records.Findings:Six client records were reviewed on April 22 and 23, 2009. A progress note after each significant contact was required in six client records. The facility failed to document a progress note after each significant contact in client records #2, 3, 4, 5 and 6. Each client was scheduled for two or three group therapy sessions daily facilitated by different counselors.. One clinical progress note was documented each day addressing only one of the group therapy sessions for the day.
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Plan of Correction
The Facility Director has revised the Service Records to accurately reflect provision of services. The Facility Director has revised the 'Frequency of Services' section on the treatment plans to accurately reflect the number of each type of group offered to clients each week. This was completed on April 24, 2009.
A progress note will be completed after each significant clinical contact. A monitor reflecting this has been added to the closed chart audit form. Results of the closed chart audits are reported monthly to the Performance Improvement Committee.
Responsible: Facility Director Deborah Voluck
Due Date: June 15, 2009 |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in four of sixteen client records.Findings:Sixteen client records were reviewed on April 22 and 23, 2009. Counseling services provided according to the individual treatment and rehabilitation plan were required in ten client records. The facility failed to document, either in the record of services or progress notes, that counseling services were provided according to the individual treatment and rehabilitation plan in client records #8, 9, 10 and 14. Individual sessions were prescribed in the treatment plan dated 4/10/09 at one time per week in client record #8. The facility did not document any individual sessions.Individual sessions were prescribed in the treatment plan dated 3/31/09 at one time per week in client record #9. The facility documented individual sessions on 4/6/09 and 4/20/09.Individual sessions were prescribed in the treatment plan dated 3/31/09 at one time per week in client record #10. The facility documented one individual session on 4/21/09. Individual sessions were prescribed in the treatment plan dated 12/10/08 at one time per week in client record #14. The facility did not document any individual sessions.
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Plan of Correction
The Facility Director trained the clinical staff on the importance of weekly individual sessions and documentation of same on April 30, 2009. Compliance will be monitored in open chart audits during regular monthly audits by the Facility Director. Compliance will be monitored in closed charts during regular monthly audits by the Director of Quality Assurance. Chart audit results reported monthly to PI Committee.
Responsible: Facility Director Deborah Voluck
Due Date: 4/30/2009 and ongoing. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document a progress note after each significant client contact in ten of ten client records.Findings:Ten client records were reviewed on April 22 and 23, 2009. A progress note after each significant contact was required in ten client records. The facility failed to document a progress note after each significant contact in client records # 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16. Each client was scheduled for two or three group therapy sessions daily by different counselors.. One clinical progress note was documented each day addressing only one of the group therapy sessions for the day.
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Plan of Correction
The Facility Director has revised the Service Records to accurately reflect provision of services. The Facility Director has revised the Frequency of Services on the treatment plans to accurately reflect the number of each type of group offered to clients each week. A progress note will be completed after each significant client contact. A new monitor has been added to the closed chart audit form to reflect this and results will be reported monthly to the Performance Improvement Committee.
This will be completed by June 15, 2009.Responsible: Facility Director Deborah Voluck
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information for two of four client records where required.Findings:Sixteen client records were reviewed on April 22 and 23, 2009. Documentation of follow-up information was required in four client records. The facility failed to document follow-up information within the required timeframe as per their own policy in client records #13 and 16. Follow-up information was undated in client record #16. Follow-up information was documented on 10/3/08 for a referral appointment which was to take place on 10/6/08 in client record #13.
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Plan of Correction
The Facility Director trained the Clinical Staff on proper follow-up policy and procedure on April 30, 2009. Compliance will be monitored by the Facility Director during regular monthly open chart audits. Compliance will be monitored in closed charts during regular monthly audits by the Director of Quality Assurance.
Chart audit results reported monthly to PI.
Responsible: Facility Director Deborah Voluck
Due Date: This was completed on 4/30/2009 and ongoing. |