INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 16, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of 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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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of eight client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in three records reviewed.
Client # 1 was admitted to the Outpatient level of care on June 11, 2024 and was discharged on November 7, 2024. The record contained a release of information form to a laboratory that was signed and dated by the client on June 11, 2024, and expired on June 11, 2024. The record contained documentation of disclosures to the laboratory on August 18, 2024, August 26, 2024, September 23, 2024, and October 15, 2024, after the consent to release form expired.
Client # 4 was admitted to the Outpatient level of care on June 5, 2024 and was discharged on October 25, 2024. The record contained release of information forms to a laboratory and a probation officer that were signed and dated by the client on June 5, 2024, and expired on June 5, 2024. The record contained documentation of disclosures to the laboratory on June 10, 2024, July 8, 2024, July 15, 2024, July 22, 2024, and July 29, 2024, after the consent to release form expired. The record also contained documentation of a disclosure of information to the probation officer on September 12, 2024, after the consent to release form expired.
Client # 5 was admitted to the Outpatient level of care on July 8, 2024 and was active at the time of the inspection. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Outpatient immediately re-educated all staff of the requirement for current and fully completed releases of information for continuity of care for each patient. OP Therapist obtained and corrected the missing funding source release of information on 12/17/2024.
Ongoing, the Director of Outpatient will monitor and audit 10 charts per month for to each client signatures on the release forms including a correct date and expiration date as required, as well as full and complete authorizations for each required entity as is pertains to the patient's care and treatment. Audit results will be reported through the Performance Improvement Committee monthly. Any deficiencies will be addressed through education and correction action where indicated.
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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 a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three of seven applicable records reviewed.
Client # 4 was admitted on June 5, 2024 and was discharged on October 25, 2024. The individual treatment and rehabilitation plan was completed on June 12, 2024, and the treatment plan update was due no later than August 11, 2024; however, the treatment plan update was not completed until August 18, 2024.
Client # 5 was admitted on July 8, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 15, 2024, and the treatment plan update was due no later than September 13, 2024; however, the treatment plan update was not completed until November 11, 2024.
Client # 7 was admitted on May 15, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 21, 2024, and the treatment plan update was due no later than July 20, 2024; however, the treatment plan update was not completed until September 21, 2024. The next treatment plan update was due to be completed by November 20, 2024; however, no treatment plan update was completed prior to the date of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Director of Outpatient immediately re-educated the Outpatient Therapists on timely documentation within the medical record including treatment plan updates being completed every 60 days after the initial master treatment plan.
Ongoing, the Director of Outpatient will monitor and audit 10 charts per month for timeliness of the treatment plan updates. Audit results will be reported through the Performance Improvement Committee monthly. Any deficiencies will be addressed through education and correction action where indicated.
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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 a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes every three months, per the facility's policy, in three of seven applicable records reviewed.
Client # 2 was admitted on May 8, 2024 and was discharged on October 30, 2024. The record did not contain a case consultation note.
Client # 3 was admitted on February 15, 2024 and was discharged on July 30, 2024. The record did not contain a case consultation note.
Client # 6 was admitted on May 13, 2024 and was active at the time of the inspection. The record did not contain a case consultation note.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Outpatient immediately re-educated the Outpatient Therapists on timely documentation within the medical record including completing a case consultation upon change in level of care and/or after 90 days in treatment.
Ongoing, the Director of Outpatient will monitor and audit 10 charts per month for timeliness of the case consultations. Audit results will be reported through the Performance Improvement Committee monthly. Any deficiencies will be addressed through education and correction action where indicated.
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