INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 12, 2014 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:
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Plan of Correction
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on the review of client records, the facility failed to provide individual counseling services at least twice a week in one out of one partial hospitalization (PH) client.
The findings include:
Two partial hospitalization client records were reviewed for documentation of individual counseling sessions on March 12, 2014. The facility failed to document verification that the minimum individual counseling sessions were provided in one out of two partial hospitalization client records, specifically record #10.
Client #10 was admitted into the PH program on August 9, 2013 and discharged on November 19, 2013. Clients in the PH program are required to have at least two individual counseling sessions each week. Based on a review of the record of services and progress notes, there was no verification that client #10 had been seen for individual counseling sessions, additionally, the client ' s treatment plan did not specifically prescribe twice a week, individual sessions.
The findings were reviewed and confirmed with the clinical supervisor, facility director, and project director.
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Plan of Correction
This standard was reviewed in the 3/24/2014 staff meeting. All partial hospitalization medical records will be audited by the clinical supervisor to ensure that individual sessions are occurring twice per week. |
709.83(a) 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:
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Observations
Based on the review of partial hospitalization (PH) client records, the facility failed to document a complete client record to include case consultations, an aftercare plan, record of services, and a discharge summary in one out of two PH client records.
The findings include:
Two partial hospitalization client records were reviewed for clinical documentation on March 12, 2014. The facility failed to document case consultations, an aftercare plan, record of services, and a discharge summary in one out of two, specifically record #10.
Client #10 was admitted on August 9, 2013, stepped down to intensive outpatient on August 23, 2013, and discharged on November 19, 2013. A case consultation is due at least once during each level of care. As of the date of inspection there was no documentation of a case consultation, an aftercare plan, or a discharge summary for client #10.
The findings were reviewed and confirmed with the clinical supervisor, facility director, and project director.
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Plan of Correction
This standard was reviewed in the 3/24/2014 staff meeting. All partial hospitalization medical records will be audited by the clinical supervisor to ensure that case consultations, aftercare plans, record of services, and a discharge summary have been completed. Results of the medical record audits will be reviewed by the clinical supervisor with the therapist in individual supervision sessions if the medical record documentation is out of ciompliance. |
709.93(a) 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:
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Observations
Based on the review of outpatient client records, the facility failed to document a complete client record to include case consultations and a record of services.
The findings include:
Eight outpatient client records were reviewed for clinical documentation on March 12, 2014. The facility failed to document case consultations and a record of services in three out of eight outpatient client records, specifically records # 2, 4, and 5.
Client #2 was admitted into the intensive outpatient program on August 2, 2013, stepped down to outpatient on September 23, 2013, and discharged on November 29, 2013. A case consultation is due at least once during each level of care. As of the date of inspection there was no documentation of a case consultation for client #2. Additionally the discharged summary was undated.
Client #4 was admitted into the intensive outpatient program on June 12, 2013, stepped down to outpatient on August 26, 2013, and discharged on September 26, 2013. A case consultation is due at least once during each level of care. As of the date of inspection there was no documentation of a case consultation for client #4.
Client #5 was admitted into the intensive outpatient program on August 22, 2013 and discharged on December 6, 2013. As of the date of inspection there was no documentation of a record of services provided for client #5.
The findings were reviewed and confirmed with the clinical supervisor, facility director, and project director.
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Plan of Correction
This standard was reviewed in the 3/24/2014 staff meeting. Open and closed medical records are audited by the clinical supervisor on a monthly basis, with results submitted to and reviewed by the Performance Improvement Committee. If case consultations and records of service are not in compliance, this information will be reviewed by the clinical supervisor and the therapist in individual supervision sessions. |