INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 27, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, TUHS 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:
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Plan of Correction
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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 written individual training plan for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor in two of four personnel records reviewed.
Employee # 3 was hired as a counselor on March 4, 2024. There was no individual training plan documented for the current training year in the personnel record at the time of the inspection.
Employee # 4 was hired as a clinical supervisor on March 4, 2024. There was no individual training plan documented for the current training year in the personnel record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, all employees will have an annual written training plan appropriate to their skill level, with input from both the employee and the supervisor. Written training plans will be monitored and updated annually in concert with employee performance evaluations. The Program Director will be responsible for ongoing monitoring of compliance with this requirement. Monitoring will occur quarterly. Any concerns/deficiencies will be addressed by the Project Director and assigned SUD clinic staff. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of fire extinguishers upon employment in two of two applicable personnel records reviewed.
Employee #3 was hired as a counselor on March 4, 2024. There was no documentation the fire extinguisher training was completed as of the date of inspection.
Employee #4 was hired as a counselor on March 4, 2024. There was no documentation the fire extinguisher training was completed as of the date of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective, July 11, 2024 SUD clinic staff will receive instruction in the use of a fire extinguisher at time of initial hire and annually thereafter. The Program Director will be responsible for ongoing monitoring of compliance with this requirement. Monitoring will occur quarterly. Any concerns/deficiencies will be addressed by the Program Director and assigned SUD clinic staff. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel on all shifts were trained to perform assigned tasks during emergencies in two of two applicable personnel records reviewed.
Employee #3 was hired as a counselor on March 4, 2024. There was no documentation the emergency preparedness training was completed as of the date of inspection.
Employee #4 was hired as a counselor on March 4, 2024. There was no documentation the emergency preparedness training was completed as of the date of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 11, 2024 SUD clinic staff will receive emergency preparedness training at time of initial hire and annually thereafter. The Program Director will be responsible for ongoing monitoring of compliance with this requirement. Monitoring will occur quarterly. Any concerns/deficiencies will be addressed by the Program Director and assigned SUD clinic staff. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's July 2023 through May 2024 fire drill logs, the facility failed to document, on their fire drill logs, which exit route was used during the fire drill.
The July 2023 through March 2024 fire drill logs did not include which exit route was used during the fire drills.
This is a repeat citation from the July 6, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 11, 2024, staff conducting fire drills in the clinic will ensure exit route used during the drill is recorded on the fire drill log. The Program Director will be responsible for ongoing monitoring of compliance with this requirement. Monitoring will occur quarterly. Any concerns/deficiencies will be addressed by the Program Director and assigned SUD clinic staff. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan with the client in seven of seven client records reviewed.
In every client record reviewed, there was no individual treatment plan completed, with the client's input, at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, individual treatment plans will be developed for each client and with client input. Documentation will be maintained in the medical record. An audit of client charts will be performed monthly to ensure compliance. The Program Director will be responsible for ongoing monitoring of compliance with this requirement. Any concerns/deficiencies will be addressed by the Program Director and assigned SUD clinic staff. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in seven of seven client records reviewed.
In every client record reviewed, there was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 11, 2024 the consent form was modified to include field to capture payor/funding source, purpose of disclosure and consent expiration date. Staff was educated about revisions to the form and requirements for completing these fields. An audit of client charts will be performed monthly to ensure compliance. The Program Director will be responsible for ongoing monitoring of compliance with this requirement. Monitoring will occur monthly. Any concerns/deficiencies will be addressed by the Program Director and assigned SUD clinic staff. |
711.93(c)(2)(iii) LICENSURE Purpose of Disclosure
711.93. Client records.
(c) Confidentiality.
(2) 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:
(iii) The purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a consent to release information form in one of two applicable client records reviewed.
Client #6 was admitted on April 8, 2024 and was still active at the time of inspection. The release of information form to another treatment provider was signed by the client on April 8, 2024; however, the release form did not include the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 11, 2024 the consent form was modified to include field to capture payor/funding source, purpose of disclosure and consent expiration date. Staff was educated about revisions to the form and requirements for completing these fields. An audit of client charts will be performed monthly to ensure compliance. The Program Director will be responsible for ongoing monitoring of compliance with this requirement. Monitoring will occur monthly. Any concerns/deficiencies will be addressed by the Program Director and assigned SUD clinic staff. |
711.93(c)(2)(vi) LICENSURE Expiration date of Consent
711.93. Client records.
(c) Confidentiality.
(2) 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:
(vi) The expiration date of the consent.
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Observations
Based on a review of client records, the facility failed to document the expiration date on informed and voluntary consent to release information forms in two of two applicable client records reviewed.
Client #3 was admitted on April 29, 2024 and was still active at the time of inspection. A release of information form to an emergency contact was signed and dated by the client on April 29, 2024; however, the release form did not include the expiration date of the consent.
Client #6 was admitted on April 8, 2024 and was still active at the time of inspection. A release of information form to another treatment provider was signed and dated by the client on April 8, 2024; however, the release form did not include the expiration date of the consent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 11, 2024 the consent form was modified to include field to capture payor/funding source, purpose of disclosure and consent expiration date. Staff was educated about revisions to the form and requirements for completing these fields. An audit of client charts will be performed monthly to ensure compliance. The Program Director will be responsible for ongoing monitoring of compliance with this requirement. Monitoring will occur monthly. Any concerns/deficiencies will be addressed by the Program Director and assigned SUD clinic staff. |