INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Upmc Western Behavioral Health At Mon Yough 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(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on the review of personnel records, the facility failed to document feedback on completed training in six of six personnel records.
Employee records # 1, 2, 3, 4, 5 and 6 did not document feedback on completed trainings.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project director will re-educate all staff on 11/16/2021 to complete a training feedback form and submit to supervisor after completing a training. Staff will sign off on signature form stating they are aware of regulation 704.11(a)(3). Supervisor reviews training form with staff monthly, effective 11/16/2021. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of personnel records, the facility failed to ensure staff received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics within the first 2 years of employment in two of two records.
Employee # 1 was hired as the project director on July 1, 2019. The HIV/AIDS and STD/TB trainings were due to be completed by July 1, 2021. There was no documentation the trainings had been completed.
Employee #3 was hired as a counselor on February 20, 2020. The HIV/AIDS and STD/TB trainings were due to be completed by February 20, 2021. There was no documentation the trainings had been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Current staff that are missing the mandatory communicable disease trainings will be scheduled to complete the HIV/AIS and an additional 4 hours of other related health topics by January 31, 2022.
Effective 11/16/2021, all new hires will complete the mandatory communicable disease training within the required time frame as outlined in 704.11(c) and training will be added to the supervision form to be reviewed, at a minimum monthly basis. Staff will sign off on signature form stating they are aware of meeting the regulation 704.11(c) requirement, effective 11/16/2021.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on the review of personnel records, the facility failed to document each counselor received at least 25 clock hours of training annually in one of one record.
The facility training year is July 1 to June 30th. The training year reviewed was July 1, 2020 to June 30, 2021.
Employee # 3 was hired as a counselor on February 2, 2020. The employee had 13.5 hours of training documented for the July 1, 2020 to June 30, 2021 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/16/2021, all staff will complete the mandatory training hours required as outlined in 704.11(f) (2) and training will be added to the supervision form to be reviewed, at a minimum monthly basis. Staff will sign off on signature form stating they are aware of meeting the regulation 704.11(f)(2) requirement, effective 11/16/2021.
Currently working on employee #3 obtaining her training hours, to be completed by Jan 31, 2021.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of the project fiscal management, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities for the fiscal year 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
UPMC Corporate Finance will obtain the services of an independent certified public accountant for an annual financial audit of UPMC Western Behavioral Health at Mon Yough's activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities, effective 11/12/2021.
UPMC Dir, Fin Compliance will ensure that MYCS has a current completed audit completed by June 1, 2022. In addition, UPMC Dir, Fin Compliane will complete an annual report for each as regulated. If unable to meet the required time frame, Dir Compliance & Regulatory will submit a waiver. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of administrative documentation, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving police and ambulance personnel.
Police were present at the facility on February 10, 2021 and August 20, 2021.
An ambulance was present at the facility on March 29, 2021.
There was no documentation the incidents had been reported to the Department.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the annual licensing inspection on October 2 - 4, 2019.
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Plan of Correction
Facility Director and supervisor re-educated all staff on 11/16/2021 regarding the necessity to use the DDAP unusual incident documents and submit unusual incidents to DDAP within 3business days via email, as well as follow internal processes. Staff will sign off on signature form stating they are aware of meeting the regulation 704.11(f)(2) requirement, effective 11/16/2021.
MYCS Facility Director will be notified of all IR and and ensure that DDAP was notified of each incident within 3 business days. The IR will be printed out and kept in a confidential binder for licensing.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records, the facility failed to ensure the treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of seven records.
Client # 1 was admitted on May 5, 2021 and was still an active client at the time of the inspection. A treatment plan update was due to be completed by October 2, 2021. The update was completed on October 11, 2021.
Client # 2 was admitted on April 13, 2021 and was still an active client at the time of the inspection. A treatment plan update was due to be completed by August 16, 2021. The update was completed on August 24, 2021.
Client # 3 was admitted on June 7, 2021 and was still an active client at the time of the inspection. A treatment plan update was due to be completed by September 14, 2021. The update was completed on October 5, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisor is running a weekly treatment plan report and sharing with all clinicians of upcoming treatment plans that are due, effective 10/26/2021. Supervisor follows up with staff during supervision of the treatment plans that are due. On 10/26/2021, Supervisor informed the clinicians that they are to complete a treatment plan without the client present in order to abide by DDAP regulations. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on the review of the policy and procedure manual, the facility failed to develop a complete written follow-up policy.
The follow-up policy did not include timeframes for which follow-up was to be completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisor will update the client follow-up policy and workflow to include a time frame of 30 days, to be completed by 11/30/2021. Facility director and supervisor will re-educate all staff by December 15, 2021, of the time frame for follow up and have them sign off on the signature form stating they are aware of meeting regulation 709.94(e) regulation. |