INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 28 - 30, 2008 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 June 5, 2008.
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Plan of Correction
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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
Based on a review of facility policy and training records on April 28, 2008, the facility failed to document an assessment of training needs within the required timeframe for each employee in ten of ten records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. The assessment of training needs forms did not include the employee's name nor the date on which the assessment form was completed.
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Plan of Correction
The assessment form has been revised to include date and time employee completes form. The Human Resources Director will conduct an audit of personnel files on a quarterly basis to ensure the form is being completed in a comprehensive manner that maintains compliance to the standard. |
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 facility policy and training records on April 28, 2008, the facility failed to document that individual training plans were completed within the required time frame identified by the facility in six of ten records reviewed, #5, 6, 7, 8, 9 and 10. Individual training plans were not dated.
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Plan of Correction
Human Resource Director will require a supervisor to include date on all training plans. A quarterly personnel file audit will be completed by Human Resources Director to ensure compliance with this standard.
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records on April 30, 2008, the facility failed to document that alternate exit routes were used during fire drills from September 2007 through April 2008.
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Plan of Correction
The form that documents which alternative route is used has been revised. The protocol for documenting the alternative routes was reviewed with the Director of Maintenance. Forms will be presented to the Safety Committee for review on a semi-monthly basis. |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based on a review of personnel records on April 28, 2008, the facility failed to document that employees were informed of their rights in ten of ten personnel records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
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Plan of Correction
A sign off sheet was created; this sheet will document that the employee has the right to review his/her personnel file. Employees will receive a copy of the Human Resource Policy that states that employees have the right to review their Human Resource File. A quarterly personnel file audit will be completed to ensure compliance with this standard. The audit will be completed by the Human Resources Director. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on the physical plant inspection on April 30, 2008, the facility failed to secure client records within locked storage containers. The closed client records were kept in unlocked shelves in a locked multipurpose room.
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Plan of Correction
A locked storage container will be placed in chart room to secure closed client records.This will be completed by 6/20/2008.
During monthly safety rounds the Director of Support Services and the Director of Quality Assurance will document compliance with securing closed charts and will report results to Safety Committee. |
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 on April 30, 2008, the facility failed to obtain an informed and voluntary consent from the client in two of seven client records reviewed, #1 and 4. The specific information to be disclosed was not identified on consents for emergency contacts.
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Plan of Correction
A training on consent forms and their proper completion will be conducted by 7/01/2008. This training will be conducted by the Director of Clinical Services and will include the necessity of identifying the specific information to be disclosed on each consent. A monthly chart audit, conducted by the Director of Quality Assurance, will monitor compliance with these consent forms. Results will be reported to the Performance Improvement committee. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of clients records on April 30, 2008, the facility failed to demonstrate that clients were informed of their rights to review their record in seven of seven records reviewed, #1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
A new form has been developed that serves as an acknowledgement that the patient has been informed of their right to review the medical record.
This form will be included in the monthly closed chart audit completed by the Director of Quality Assurance with results reported to the Performance Improvement Committee. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on April 30, 2008, the facility failed to document a complete psychosocial evaluation in three of three client records reviewed, #2, 3 and 4. Psychosocial evaluations were a repeat of historical data and did not include a clinical assessment of how assets/strengths, support systems and negative factors would impact the potential for treatment.
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Plan of Correction
1. A training will be held on completion of psychosocial evaluations that will include the need for a clinical assessment to guide the treatment planning process. This training will be completed by 7/15/2008. The training will be completed by the Director of Clinical Services.
2. Monthly closed chart audits will be completed by the Director of Quality Assurance. Chart audit results on timeliness of psychosocial completion are submitted to the Performance Improvement Committee on a monthly basis. |
709.63(a)(6) LICENSURE Aftercare plan
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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records on April 30, 2008, the facility failed to document an aftercare plan in one of three client records reviewed, #3.
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Plan of Correction
1. Aftercare plan completion are included in monthly clodsed chart audits by the Director of Quality Assurance. Chart audit results are reported to the Performance Improvement Committee.
2. A staff training will be held by 7/15/2008 to review the aftercare plan policy and procedure by the Director of Clinical Services. Staff failure to comply with the policy will subject the staff to KeyStone's progressive disciplinary policy. |
709.63(a)(8) LICENSURE Follow-up Information
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:
(8) Follow-up information.
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Observations
Based on a review of client records on April 30, 2008, the facility failed to document follow-up information for one of two client records, #3.
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Plan of Correction
1. A training will be held by 7/31/2008 that will focus on follow-up policy and procedure. The training will be conducted by the Director of Clinical Services.
2. Follow up compliance is audited by a sample of closed charts. This is completed by the Director of Quality Assurance with results reported to the Performance Improvement Committee. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on April 30, 2008, the facility failed to document a complete psychosocial evaluation in five of five client records reviewed, #1, 2, 3, 4 and 5. The evaluations were a repeat of historical data and did not include a clinical assessment of how assets/strengths, support systems and negative factors would impact the potential for treatment nor did they include the client's attitude toward treatment.
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Plan of Correction
A training will be held on completion of psychosocial evaluations that will include the need for a clinical assessment to guide the treatment planning process. This training will be completed by 7/15/2008. The training will be completed by the Director of Clinical Services.
2. Monthly closed chart audits will be completed by the Director of Quality Assurance. Chart audit results on timeliness of psychosocial completion are submitted to the Performance Improvement Committee on a monthly basis.
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709.52(a)(1) LICENSURE Short/Long term TX Goals
709.52. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records on April 30, 2008, the facility failed to document treatment plan goals stated in terms of measurable criteria in two of five client records reviewed, #4 and 5.
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Plan of Correction
A treatment planning staff training will be held by 7/31/2008 that will address the need for treatment plan goals to be documented in terms of measurable criteria. This will be completed by the Director of Clinical Services. Treatment plan completion including specific goals will be added to the monthly closed chart audits to be conducted by the Director of Quality Assurance with results reported to the Performance Improvement Committee. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records on April 30, 2008, the facility failed to document that the treatment plan update was completed within the required timeframe of 15 days in one of one client records reviewed, #3. The treatment plan update was late.
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Plan of Correction
1. Treatment plan update completion and compliance is audited on a monthly basis through closed chart audits with results reported to the Performance Improvement Committee. The audits are conducted by the Director of Quality Assurance.
2. A staff training will be held by 7/31/2008 that will review the treatment plan update policy and procedure. This training will be conducted by the Director of Clinical Services. |
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 on April 30, 2008, the facility failed to document that counseling services were provided according to the individual treatment plan in four of five client records reviewed, #1, 3, 4 and 5. Treatment plans prescribed one individual session per week. Client records #1, 4 and 5 had no individual sessions documented. Client record #3 had only two of four required individual sessions documented.
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Plan of Correction
A clinical staff training will be held to address compliance with weekly individual sessions. The training will include appropriate documentation of individual sessions. This training will be conducted by the Director of Clinical Services and will be held by 7/15/2008.
A closed chart audit will be conducted by the Director of Quality Assurance to ensure compliance with standard. Results will be reported on a monthly basis to the Performance Improvement Committee. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records on April 30, 2008, the facility failed to document an aftercare plan for one of two client records where an aftercare plan was required, #5.
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Plan of Correction
1. Aftercare plans are audited on a monthly basis by the Director of Quality Assurance with results reported to the Performance Improvement Committee. 2. A staff training will be held by 7/15/2008 to review the aftercare plan policy and procedure. This will be conducted by the Director of Clinical Services. |