INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 2, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, UPMC Mercy 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the facility ' s Staffing Requirement Facility Summary Report (SRFSR), the facility failed to have a full-time clinical supervisor for every eight full-time counselors and/or counselor assistants.
The full-time equivalent (FTE) calculation for the number of clinical supervisors needed is as follows:
The total # of hours project-wide devoted to D&A clients divided by the project ' s standard workweek.
The project calculation was: 320 hours / 40 hours = 8 FTE.
The project must have a full-time clinical supervisor on staff for every 8 FTE clinical staff; however, the facility did not have a clinical supervisor at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility is in the process of creating a role to function as the Clinical Supervisor to support the counselors who staff the Detoxification unit at UPMC Mercy Hospital. This position will be called, Supervisor of Clinical Care Coordination and Discharge Planning. This position has been approved by the hospital's CNO, Human Resources Department, and financial teams. It is in the final stages of development before being posted for recruitment. We anticipate this position will be filled no later than 3/1/2026. |
710.23(a) LICENSURE Patient Records
§ 710.23. Patient records.
(a) In addition to the requirements contained in § 115.32 (relating to contents), the patient ' s medical record shall contain a drug and alcohol support plan, follow-up information, and an aftercare plan, if applicable.
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Observations
Based on a review of applicable patient records, the facility failed to ensure the patient ' s medical record contain a drug and alcohol support plan, follow-up information, and an aftercare plan in two of two records. The facility ' s policy states that follow-up will be completed seven and thirty days after discharge with signed client consent.
Patient #6 was admitted on May 21, 2025 and discharged on May 27, 2025. The seven-day follow-up was due no later than June 3, 2025 and the thirty-day follow-up was due no later than June 27, 2025. There was no documentation of follow-up at the time of the inspection.
Patient #7 was admitted on August 7, 2025 and discharged on August 12, 2025. The seven-day follow-up was due no later than August 19, 2025; however, this was not completed at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The unit is in the process of creating a Clinical Supervisor position to assist with the day-to-day planning and development of the program. This includes chart audits/reviews, policy updates, and assisting counseling staff members when needed. The specific task of completing follow-up phone calls with individuals discharged from the 4WM program will fall onto this position as well as the unit Milieu Therapist. We anticipate by 01/02/2026, our follow-up phone call compliance rates will have improved based on these two changes. |