INITIAL COMMENTS
|
This report is a result of an on-site licensing inspection and NTP montorining inspeciton. This inspection was conducted on December 14-15 and 17, 2015 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 4 PA Code and 28 PA Code which pertain to the facility.
|
Plan of Correction
|
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
|
Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consents in two of nineteen records reviewed.
The findings include:
Nineteen client records were reviewed on December 14, 2015. All were reviewed for informed and voluntary consent forms. The facility failed to document if the client was offered a copy of the informed and voluntary consent forms.
Client #4 - The facility failed to document on the consent to release dated December 14, 2015 for the client ' s provider whether or not the client was offered a copy of the consent.
Client #9 - The facility failed to document on the consent to release dated December 14, 2015 for the client ' s provider whether or not the client was offered a copy of the consent. Additionally, the facility failed to document on a consent to release dated December 11, 2015 to a provider the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
709.28(d)
In a staff meeting on January 6, 2016, clinical staff was re-educated by the Director of Clinical Services regarding the importance of documenting whether or not the client receives a copy of each consent to release. Additionally, at the same meeting, clinical staff was re-educated regarding the need to clearly document on the consent to release the purpose of the disclosure. Charts active at time of licensing visit will be corrected by 2/26/2016. Compliance will be monitored by Clinical Director and Clinical Coordinator in regular monthly open and closed chart audits.
|
709.28(e)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(e) Where consent is not required, the project personnel shall:
(2) Inform the client, as readily as possible, that the information was disclosed, for what purposes and to whom.
|
Observations
Based on a review of client records, the facility failed to adhere to the limitations imposed under 4 Pa. Code 255.5 in five of nineteen records.
The findings include:
4 Pa. Code states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Nineteen client records were reviewed on December 14, 2015. The facility released information that exceeded the limitations imposed under 4 Pa. Code 255.5 in client record # 18, 6, 7, 10, 8
Client #6 - Consent to release form dated August 14, 2015 for a government agency, allowed for the release of the following documents: demographic information
Client #7 - Consent to release form dated July 29, 2015 for a government agency, allowed for the release of the following documents: demographic information
Client #8 - Consent to release form dated July 7, 2015 for a government agency, allowed for the release of the following documents: demographic information
Client #10- Consent to release form dated July 12, 2015 for a government agency, allowed for the release of the following documents: demographic information
Client #18 - Consent to release form dated June 6, 2015 for a government agency, allowed for the release of the following documents: demographic information
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
709.28(e)(2)
In an Admissions Staff Meeting held on January 6, 2016, staff was re-educated by the Director of Admissions regarding the release of demographic information. The category "demographic information" was removed from all releases.Charts active at time of licensing visit will be corrected by 2/26/2016. Compliance will be monitored in regular monthly chart audits conducted by Admissions staff.
|
705.1 (1) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(1) Hold a license under Chapter 709 (relating to standards for licensure of freestanding treatment facilities) or a certificate under Chapter 711 (relating to standards for certification of treatment activities which are part of a health care facility).
|
Observations
Based on the review of the facilities fire drill record, the facility failed to document overnight fire drills every six months.
Findings:
The fire drill record was reviewed on December 14, 2015. The first overnight fire drill reviewed was conducted on November 19, 2014. The next overnight fire drill wasn ' t conducted until June 17, 2015.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
705.10 (d) (5)
The Plant Operations Manager will ensure that the Facility conducts a fire drill during sleeping hours at least every 6 months. Sleeping hours are defined as after 10:30 PM and before 6:30 AM. A review of drill compliance will take place monthly in the Facility's Safety 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.
|
Observations
Based on a review of client records, the facility failed to complete psychosocial evaluations in five of ten short-term detoxification client records.
Findings:
Nineteen client records were reviewed on December 14 and 17, 2015. Ten client records were from the short-term detoxification activity, 1-10. Psychosocial evaluations were required in ten short-term detoxification client records. The psychosocial evaluations were disjointed with listed responses and client reported comments rather than a clinical assessment of the when it came to the client composite picture, clients problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, clients attitude toward treatment and the counselors impression/impression of the client in client records #6, 7, 8, 9 and 10.
|
Plan of Correction
709.62 (c) (6)
The psychosocial evaluation summary form is being revised. The new form will provide prompts to elicit information about clients' problems/needs, assets/strengths, support systems, coping mechanisms, factors inhibiting treatment, attitude toward treatment and counselor's impression of the client. Clinical Supervisors will educate staff regarding the completion of the new format. Staff will sign off indicating their understanding. The new form will then become operational by February 15, 2016. Compliance will be monitored by Clinical Director and Clinical Coordinator in monthly open and closed chart audits.
|
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to complete psychosocial evaluations in three of nine short-term rehabilitation client records.
Findings:
Nine client records were reviewed on December 14 and 17, 2015. Nine client records were from the short-term rehabilitation activity, 11-19. Psychosocial evaluations were required in nine short-term rehabilitation client records. The psychosocial evaluations were disjointed with listed responses and client reported comments rather than a clinical assessment of the when it came to the client composite picture, clients problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, clients attitude toward treatment and the counselors impression/impression of the client in client records #16, 17 and 19.
|
Plan of Correction
709.51(b) (6)
The psychosocial evaluation summary form is being revised. The new form will provide prompts to elicit information about clients' problems/needs, assets/strengths, support systems, coping mechanisms, factors inhibiting treatment, attitude toward treatment and counselor's impression of the client. Clinical Supervisors will educate staff regarding the completion of the new format. Staff will sign off indicating their understanding. The new form will then become operational by February 15, 2016. Compliance will be monitored by Clinical Director and Clinical Coordinator in monthly open and closed chart audits.
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
Based on the review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of three personnel records.
The findings include:
Fourteen personnel records were reviewed on December 14, 2015. One personnel record was required to include documentation of their qualifications and experience for the position of counselor. The facility failed to provide documentation of the counselor ' s experience in personnel record #7.
Employee #7 was hired as a counselor on October 27, 2015 and had the required degree for the position. The facility failed to show documentation that employee #7 had the required 1 year clinical experience.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
704.7(b)
Human Resource Director will insure that the identified Counselor will have their position changed from Counselor to Counselor Aide until she meets the one year of required clinical experience effective 10/27/2016. Affected employee has been given new job description which has been signed by employee and supervisor to reflect change. Human Resource Director and Facility Director will review credentials of all prospective staff candidates with regard to DOH Staffing Qualifications (CH. 704) to assure proper classification and compliance. Human Resource Director will perform quarterly personnel file audits to assure compliance.
|