INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 12, 2022 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 of the Alleghenies 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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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of the facility annual report, the governing body failed to include a statement disclosing the names of officers, directors and principal shareholders.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to 6/1/22 the Compliance Officer will re-educate the Project Director on regulation 709.22 that the Annual D&A Report/Plan will include the names of the officers, directors and principal shareholder. The Project Director will assure on an annual basis that the Drug and Alcohol Report/ Plan shall include a statement disclosing the names of officers, directors and principal share holders and make said report available to the public annually. |
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 two of five applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records # 5 and # 7.
Client # 5 was admitted on June 18, 2021 and was discharged on January 14, 2022. A treatment and rehabilitation plan was developed on June 29, 2021. A treatment and rehabilitation plan update was due no later than August 29, 2021 however, a treatment and rehabilitation plan update did not occur until September 9, 2021.
Client # 7 was admitted on July 28, 2021 and was discharged on February 1, 2022. A treatment and rehabilitation plan was developed on August 25, 2021. A treatment and rehabilitation plan update was due no later than October 25, 2021 however, a treatment and rehabilitation plan update did not occur until December 17, 2021.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 17, 2021 annual licensing inspection.
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Plan of Correction
On June 1, 2022, facility director will educate staff during weekly staff meeting regarding the requirements to ensure all clients and have active and current treatment plan. This education will include that the individual must be present for the development of the initial comprehensive treatment plan; but treatment plan updates can be completed without the individual present in cases where the individual did not attend the session at which the treatment plan update was to occur. In addition, the education will include that if the treatment plan is updated without the individual, it is to be reviewed at the next attended treatment session to ensure person-centered care. Facility director will have staff sign off on the treatment plan requirements during staff meeting.
Facility director will continue to utilize an updated documentation tracker to track treatment plan due dates. Facility director will send a highlighted copy of the documentation tracker weekly to staff members. Facility director will be responsible to review documentation tracker completion weekly during supervision with staff to check for treatment plan completion. If staff do not complete treatment plans according to date listed on documentation tracker, disciplinary action will be taken per UPMC policy (verbal warning, written warning, performance improvement plan).
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on three of six applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a case consultation to occur at least every ninety days.
Client # 1 was admitted on December 17, 2021 and was still active at the time of the inspection. A case consultation was completed on January 5, 2022. Another case consultation was due to occur no later than April 5, 2022. The next case consultation documented in the client record occurred on May 3, 2022.
Client # 3 was admitted on January 20, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than April 20, 2022. There was no case consultation documented in the client record.
Client # 5 was admitted on June 18, 2021 and was discharged on January 14, 2022. A case consultation was due to occur no later than September 18, 2021. A case consultation documented in the client record occurred on October 21, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On June 1, 2022, program supervisor will educate staff during weekly staff meeting regarding the requirement to ensure all clients have case consults completed every 90 days. Program supervisor will have staff sign off on the case consult requirements during staff meeting.
Program supervisor will continue to utilize an updated documentation tracker to track case consult due dates. Program supervisor will send a highlighted copy of the documentation tracker weekly to staff members. Program supervisor will be responsible to review documentation tracker completion weekly during supervision with staff to check for case consult completion. If staff do not complete case consults according to date listed on documentation tracker, disciplinary action will be taken per UPMC policy (verbal warning, written warning, performance improvement plan).
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