INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 28, 2010 through April 29, 2010 licensure renewal inspection. The follow-up inspection was conducted on October 26, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 December 1, 2010.
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Plan of Correction
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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
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.
This could not be re-evaluated until the next licensing inspection because there were no partial hospitalization client records to review. Please resubmit the original plan of correction.
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Plan of Correction
Outpatient Director will conduct training on November 30, 2010 to review with staff the follow-up policy and will re-implement the start of the therapists documenting follow-ups within 60 to 90 days of the client's discharge so as not to be late on calls made. The follow-up call sheets will be placed in a binder in the chart room. Outpatient Director will conduct random chart audits on weekly basis and report results to PI Committee monthly to monitor compliance. Attendance percentage of staff trainings will also be reported to PI. |
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 discussion with the facility director, the facility failed to document that counseling was provided to the client on a regular and scheduled basis in six of six client records.
The findings include:
Thirteen client records were reviewed on October 26, 2010. Six of those records were reviewed for counseling provided to the client on a regular and scheduled basis. 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 completion of treatment plan updates in client records #2, 3, 4, 5, 6 and 7.
This is a repeat citation from the April 28, 2010 through April 29, 2010 licensure renewal inspection.
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Plan of Correction
Outpatient Director will conduct training on November 30, 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 12/1/10. Outpatient Director will conduct random chart audits on a weekly basis and report results to PI Committee monthly to monitor compliance. Attendance percentage of staff trainings will also be reported to PI. |
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 according to facility policy in six of six client records.
The findings include:
Thirteen client records were reviewed on October 26, 2010. Documentation of follow-up information was required in six 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 #8 was discharged on July 12, 2010, and follow-up was due to be completed on or before October 12, 2010. Follow-up was documented on October 14, 2010 for client record #8.
Client #9 was discharged on July 7, 2010, and follow-up was due to be completed on or before October 7, 2010. Follow-up was documented on October 14, 2010 for client record #9.
Client #10 was discharged on July 7, 2010, and follow-up was due to be completed on or before October 7, 2010. As of October 26, 2010, follow-up was not documented for client record #10.
Client #11 was discharged on July 5, 2010, and follow-up was due to be completed on or before October 5, 2010. Follow-up was documented on October 14, 2010 for client record #11.
Client #12 was discharged on July 12, 2010, and follow-up was due to be completed on or before October 12, 2010. Follow-up was documented on October 14, 2010 for client record #12.
Client #13 was discharged on July 2, 2010, and follow-up was due to be completed on or before October 2, 2010. Follow-up was documented on October 26, 2010 for client record #13.
This was confirmed by the facility director.
This is a repeat citation from the April 28, 2010 through April 29, 2010 licensure renewal inspection.
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Plan of Correction
Outpatient Director will conduct training on November 30, 2010 to review with staff the follow-up policy and will re-implement the start of the therapists documenting follow-ups within 60 to 90 days of the client's discharge so as not to be late on calls made. The follow-up call sheets will be placed in a binder in the chart room. Outpatient Director will conduct random chart audits on weekly basis and report results to PI Committee monthly to monitor compliance. Attendance percentage of staff trainings will also be reported to PI |