INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 28, 2010 through April 29, 2010 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, 2010.
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Plan of Correction
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709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment plan in one of one client record.
The findings include:
One client record was available to review on April 29, 2010. An individual treatment plan including documentation of the type and frequency of treatment and rehabilitation services was required in one client record. The individual treatment plan in client record #1 did not include documentation of the type and frequency of treatment and rehabilitation services.
This was confirmed by the facility director.
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Plan of Correction
Outpatient Director will change the existing treatment plan to add "type and frequency of treatment and rehabilitation services" by June 1, 2010 and will conduct a training on June 8, 2010 with all staff to review new treatment plan and implement the new treatment plan for all new clients. Outpatient Director will conduct random chart audits on weekly basis and report results to PI Committee monthly to monitor compliance. |
709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. 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 client records and an interview with the facility director, the facility failed to document proposed support services on the individual treatment plan in one of one client record.
The findings include:
One client record was available to review on April 29, 2010. An individual treatment plan including documentation of proposed support services was required in one client record. The individual treatment plan in client record #1 did not include documentation of proposed support services.
This was confirmed by the facility director.
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Plan of Correction
Outpatient Director will change the existing treatment plan to add "type of support services" by June 1, 2010 and will conduct training on June 8, 2010 with all staff to review new treatment plan and implement the new treatment plan for all new clients. Outpatient Director will conduct random chart audits on weekly basis and report results to PI Committee monthly to monitor compliance. |
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
Based on the review of client records, the facility's policy and procedure manual, and an interview with the facility director, the facility failed to document follow-up information in one of one client record.
The findings include:
One client record was available to review on April 29, 2010. Documentation of follow-up information was required in one client record. According to the facility's follow-up policy, follow-up is to be completed on all clients not referred for other treatment within three months of the date of discharge. Client #1 was discharged on January 21, 2010, and follow-up was due to be completed on or before April 21, 2010. As of April 29, 2010, follow-up was not documented for client record #1.
This was confirmed by the facility director.
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Plan of Correction
Outpatient Director will conduct training on June 8, 2010 for staff to review the follow-up policy and will implement the re-start of the therapists documenting follow-ups within 90 days of a client's discharge in the follow-up tracking folder. Outpatient Director will conduct random chart audits on weekly basis and report results to PI Committee monthly to monitor compliance. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment plan in seven of seven client records.
The findings include:
Seven client records were reviewed on April 29, 2010. An individual treatment plan including documentation of the type and frequency of treatment and rehabilitation services was required in seven client records. The individual treatment plan in client records #2, 3, 4, 5, 6, 7 and 8 did not include documentation of the type and frequency of treatment and rehabilitation services.
This was confirmed by the facility director.
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Plan of Correction
Outpatient Director will change the existing treatment plan to add "type and frequency of treatment and rehabilitation services" by June 1, 2010 and will conduct a training on June 8, 2010 with all staff to review new treatment plan and implement the new treatment plan for all new clients. Outpatient Director will conduct random chart audits on weekly basis and report results to PI Committee monthly to monitor compliance. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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 client records and an interview with the facility director, the facility failed to document proposed support services on the individual treatment plan in seven of seven client records.
The findings include:
Seven client records were reviewed on April 29, 2010. An individual treatment plan including documentation of proposed support services was required in seven client records. The individual treatment plan in client records #2, 3, 4, 5, 6, 7 and 8 did not include documentation of proposed support services.
This was confirmed by the facility director.
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Plan of Correction
Outpatient Director will change the existing treatment plan to add "type of support services" by June 1, 2010 and will conduct training on June 8th with all staff to review new treatment plan and implement the new treatment plan for all new clients. Outpatient Director will conduct random chart audits on weekly basis and report results to PI Committee monthly to monitor compliance. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records and interview with the facility director, the facility failed to document that counseling was provided to the client on a regular and scheduled basis in seven of seven client records.
The findings include:
Seven client records were reviewed on April 29, 2010. Counseling provided to the client on a regular and scheduled basis was required in seven client records. There was no documentation of at least one individual session on the 30th day for development of the comprehensive treatment plan and there was no documentation every 60 days for the completion of treatment plan updates in client records #2, 3, 4, 5, 6, 7 and 8. This is a repeat citation from the April 27, 2009 licensing inspection.
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Plan of Correction
Outpatient Director will conduct training on June 8, 2010 for the staff to review the new procedure of documenting review of treatment plans and updated treatment plans with clients in an individual session in a progress note. This procedure will be initiated on 6/8/10. Outpatient Director will conduct random chart audits on weekly basis and report results to PI Committee monthly to monitor compliance. |
709.93(a)(2) LICENSURE Client records
709.93. 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:
(2) Medication records.
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Observations
Based on a review of client records and interview with the facility director, the facility failed to document medication records to include the name of the drug, dosage and frequency of use in two of four client records.
The findings include:
Seven client records were reviewed on April 29, 2010. Documentation of medication records to include the name of the drug, dosage and frequency of use was required in four client records. The medication records in client records #3 and 5 only included the name of the medication. There was no documentation of the dosage or frequency of use.
This was confirmed by the facility director.
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Plan of Correction
Outpatient Director will conduct training on June 8, 2010 for the staff to review how to correctly document clients' medication with the medication, dosage and frequency of each medication the client is prescribed on the assessment form. The staff will be directed to ask clients' to bring medication information to the assessment appointment during the initial intake call. This procedure will also be discussed at the training. This procedure will be initiated on 6/8/10. Outpatient Director will conduct random chart audits on weekly basis and report results to PI Committee monthly to monitor compliance. |
709.93(a)(11) LICENSURE Client records
709.93. 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 the review of client records, the facility's policy and procedure manual, and an interview with the facility director, the facility failed to document follow-up information in two of three client records.
The findings include:
Seven client records were reviewed on April 29, 2010. Documentation of follow-up information was required in three client records. According to the facility's follow-up policy, follow-up is to be completed on all clients not referred for other treatment within three months of the date of discharge. Client #6 was discharged on January 7, 2010, and follow-up was due to be completed on or before April 7, 2010. As of April 29, 2010, follow-up was not documented for client record #6. Client #8 was discharged on December 28, 2009, and follow-up was due to be completed on or before March 28, 2010. As of April 29, 2010, follow-up was not documented for client record #8.
This was confirmed by the facility director.
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Plan of Correction
Outpatient Director will conduct training on June 8,2010 for staff to review the follow-up policy and will implement the re-start of the therapists documenting follow-ups within 90 days of a client's discharge in the follow-up tracking folder. Outpatient Director will conduct random chart audits on weekly basis and report results to PI Committee monthly to monitor compliance. |