INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26, 2007 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 and a plan of correction is due on August 30, 2007.
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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
The facility failed to obtain an informed and voluntary consent to release information in five of ten client records reviewed, #1, 3 and 5 (outpatient activity) and #1 and 2 (partial hospitalization activity). Consent to release information forms did not identify the name or organization the information was being released to, the specific information to be released or the purpose for the release.
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Plan of Correction
The project was not in compliance with this standard because of inconsistency in completion of consent forms.
An in-service training for the outpatient clinical staff is scheduled to occur on September 13, 2007 by the Director of Outpatient Services. Areas/topics to be addressed include releases to, and from and the specific purpose of the release. Clarification on the specific information to be released and its purpose will also be covered. The project will be in full compliance with this standard by 9/30/07. Monitoring of completion of documentation will occur by program director and site manager through the Performance Improvement (PI) process on a monthly basis.
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709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The facility failed to document a complete drug and alcohol history in four of four client records reviewed, #1, 2, 3 and 4. The clients's perception was not addressed.
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Plan of Correction
The project was not in compliance with this standard because of incomplete documentation of historical information. The Director of Outpatient will conduct an in-service training on Sept. 17, 2007 to address the Intake and admission process. Lengths and patterns of the client's use are also to be identified during this training. The project will be in full compliance with this standard by 9/30/07. Monitoring of completion of documentation will occur by program director and site manager through the Performance Improvement (PI) process on a monthly basis. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to document a complete psychosocial evaluation in four of four client records reviewed, #1, 2, 3 and 4. Psychosocial evaluation was historical rather than evaluative and failed to include clinical impressions and opinions regarding the client's problems/needs, assets/strengths, support systems, clients attitude towards treatment, clinical impressions/conclusions and coping mechanisms.
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Plan of Correction
The project was not in compliance with this standard because documentation lacked detail, substance and clinical impression. In-service training for all clinical outpatient staff is scheduled to occur on Sept. 17, 2007.
Areas to be stressed are the formulation of clinical impressions regarding the client's areas of strength, support systems, attitude toward treatment and their preferred coping mechanisms. Specific areas to be highlighted are the evaluative nature of an assessment and the importance of including the client's perception of their use/problem. The project will be in full compliance with this standard by 9/30/07. Monitoring of completion of documentation will occur by program director and site manager through the Performance Improvement (PI) process on a monthly basis.
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
The facility failed to provide individual counseling to clients in four of four records reviewed, #1, 2, 3 and 4.
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Plan of Correction
The project was not in compliance with this standard because documentation did not support the required frequency of service for individual counseling.
Requirement for partial client's individual counseling services will be reviewed with Partial counselor in a supervisory session on August 24, 2007. The project will be in full compliance with this standard by 9/15/07.
Monitoring of completion of documentation will occur by program director and site manager through the Performance Improvement (PI) process on a monthly basis.
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709.83(a)(6) LICENSURE Client records
709.83. 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:
(6) Aftercare plans, if applicable.
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Observations
The facility failed to document aftercare plans in two of two records reviewed, #3 and 4.
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Plan of Correction
The project was not in compliance with this standard because documentation was lacking in support of aftercare plans. Formulation of aftercare plans will be reviewed in a clinical staff in-service on September 21, 2007 for all outpatient staff. The project will be in full compliance with this standard by 9/30/07.
Monitoring of completion of documentation will occur by program director and site manager through the Performance Improvement (PI) process on a monthly basis.
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709.83(a)(11) LICENSURE Client records
709.83. 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
The facility failed to document follow-up information in two of two client records reviewed, #3 and 4.
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Plan of Correction
The project was not in compliance with this standard because documentation was lacking in support of post-discharge follow-up. In-service training on Sept. 21, 2007 will include the importance of obtaining follow-up information on clients who left treatment or transitioned to another level of care. The project will be in full compliance with this standard by 9/30/07. Monitoring of completion of documentation will occur by program director and site manager through the Performance Improvement (PI) process on a monthly basis. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The facility failed to document a complete drug and alcohol history in six of six client records reviewed, #1, 2, 3, 4, 5 and 6. The clients's perception was not addressed.
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Plan of Correction
The project was not in compliance with this standard because of incomplete documentation of historical information. The Director of Outpatient will conduct an in-service training on Sept. 17, 2007 to address the Intake and admission process. Specific areas to be highlighted are the evaluative nature of an assessment and the importance of including the client's perception of their use/problem. Lengths and patterns of the client's use are also to be identified during this training. The project will be in full compliance with this standard by 9/30/07.Monitoring of completion of documentation will occur by program director and site manager through the Performance Improvement (PI) process 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
The facility failed to document a complete psychosocial evaluation in six of six client records reviewed, #1, 2, 3, 4, 5 and 6. Psychosocial evaluation was historical rather than evaluative and failed to include clinical impressions and opinions regarding the client's problems/needs, assets/strengths, support systems, clients attitude towards treatment, clinical impressions/conclusions and coping mechanisms.
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Plan of Correction
The project was not in compliance with this standard because documentation lacked detail, substance and clinical impression. The Director of Outpatient will conduct an in-service training on Sept. 17, 2007 to address the Intake and admission process. Specific areas to be highlighted are the evaluative nature of an assessment and the importance of including the client's perception of their use/problem. Lengths and patterns of the client's use are also to be identified during this training. Client's attitude toward the treatment process and the preferred coping mechanisms will be included in this training.
The project will be in full compliance with this standard by 9/30/07. Monitoring of completion of documentation will occur by program director and site manager through the Performance Improvement (PI) process on a monthly basis.
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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
The facility failed to document treatment plan updates in four of five records reviewed,#1, 3, 5 and 6.
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Plan of Correction
The project was not in compliance with this standard because treatment plan updates were not documented consistently. Time frames for completion of clinical documentation particularly treatment plans and updates will be reviewed at the clinical team meeting scheduled for September 27, 2007. The project will be in full compliance with this standard by 9/30/07. Monitoring of clinical documentation will occur by program director and site manager and is included in the monthly PI reviews. |
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on the review of personnel record, the facility failed to document supervision for one of one counselor assistant. Weekly direct observation was not documented for employee #5.
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Plan of Correction
The project was not in compliance with this standard because direct observation of supervisee was not correctly documented. Weekly direct observation of a counselor assistant will be conducted and correctly documented by the Program Director effective immediately. |
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
The facility failed to document an assessment of staff training needs in three of five employee records reviewed, #1, 2 and 4.
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Plan of Correction
The project was not in compliance with this standard as a result of misinterpretation of the standard. An assessment of staff training needs will be distributed to all employees on an annual basis. The needs assessment form will be placed in the employees personnel file. Human Resource Director will audit files on quarterly basis to assure compliance. The project will be in full compliance with this standard by 9/15/07. |
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
The facility failed to document individual training plans for employees in five of five training records reviewed, #1, 2, 3, 4 and 5.
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Plan of Correction
The project was not in compliance with this standard as a result of misinterpretation of the standard. An existing mechanism is in place to collect feedback. Data was colleted and reported to Board of Governors and utilized to implement yearly staff Development Plan. The Human Resource Director will ensure feedback forms on all in-services will be distributed and placed in personnel files. The project will be in full compliance with this standard by 9/15/07. |
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
The facility failed to document an individual training plan in two of five employee records reviewed, #2 and 4.
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Plan of Correction
The project was not in compliance with this standard as a result of misinterpretation of the standard. Individual training plans will be completed with all staff annually. Human Resource Director will audit files on quarterly basis to assure compliance. The project will be in full compliance with this standard by 9/15/07. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The facility failed to provide a sufficient number of persons certified in CPR and trained in first aid during the evening hours. Two of four employees were not certified in CPR and trained in first aid.
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Plan of Correction
The project was not in compliance with this standard because it lacked sufficient trained staff to account for all variables of staffing. All staff will be certified in CPR/First Aid by September 30, 2007. Until this occurs, staff schedules will be synchronized to assure that at least one certified staff member is in the building when patients are present. Program Director to assure compliance. |