INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 31, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, conducted January 31, 2018 at approximately 2:30 pm, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room as there was not any window treatments covering the window in the door of the large conference room, that had a session going on at time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The missing door blind was immediately reported to the Maintenance Department and was replaced on 2/9/2018. Clinical activities were not permitted in the identified area until the blind had been replaced. Staff has been informed not to provide treatment in any area where a mechanism does not exist to provide confidentiality. Staff has been further informed to report all associated environmental/maintenance deficiencies to the Program Director and to the Maintenance Department via the work order system that is already in place. |
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 the review of 7 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 4 client records.
Client #1 was admitted into the outpatient level of care on 11/14/16 and was still active at the time of the inspection. There were release of information forms to the funding source and the urinalysis lab both dated 11/14/16 and expired on 11/14/17. The client signed and dated updated release forms for both agencies on 12/5/17. However, there was documentation that communication was made between the facility and both agencies between the expiration date of the first release form and the date of the updated release form.
Client #2 was admitted into the outpatient level of care on 9/2/16 and was still active at the time of the inspection. There were release of information forms to the funding source, a probation officer, a doctor, and the urinalysis lab all dated 9/12/16 and expired on 9/12/17. The client signed and dated updated release forms for all agencies on 1/9/18. However, there was documentation that communication was made between the facility and all the agencies between the expiration date of the first release form and the date of the updated release form.
Client #4 was admitted into the outpatient level of care on 8/23/16 and was discharged 10/19/17. There were release of information forms to the funding source, the probation officer, and the urinalysis lab all dated 8/23/16 and expired on 8/23/17. There was documentation that communication was made between the facility and all the agencies after the expiration date of the release form and before the date of client's discharge without an updated, client-signed consent to release information form in place for each agency prior to disclosure.
Client #7 was admitted into the outpatient level of care on 10/20/16 and was discharged 11/20/17. There were release of information forms to the funding source, a hospital, a significant other, the probation officer, and the urinalysis lab all dated 10/20/16 and expired on 10/20/17. There was documentation that communication was made between the facility and all the agencies/individuals after the expiration date of the release form and before the date of client's discharge without an updated, client-signed consent to release information form in place for each agency prior to disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff was re-educated on 2/5/18 regarding procedures for maintaining active client consents for releases of information. Outdated releases for clients who are currently active in the program have been updated. The Program Director will monitor adherence through monthly chart audits and results will be reported and monitored through Keystone Center's (parent agency) Performance Improvement Committee. |
709.93(b) LICENSURE Client records
709.93. Client records.
(b) The project shall develop and maintain client records on standardized project client record forms.
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Observations
Based on a review of 7 client records, 3 client records had treatment plan updates completed after the regulatory timeframe or missing at the time of the inspection.
Client #1 was admitted on 11/14/16 and was active at the time of inspection. A treatment plan update was completed 1/12/17 and the next update was due no later than 3/12/17. However, the update was not completed until 3/22/17.
Client #4 was admitted on 8/23/16 and was discharged on 10/19/17. A treatment plan was completed 2/25/17 and the next update was due no later than 4/25/17. However, the update was not completed until 6/29/17.
Client #7 was admitted on 10/20/16 and was discharged on 11/20/17. A treatment plan update was completed 4/20/17 and the next update was due no later than 6/20/17/17. However, the update was not completed until 6/29/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff was re-educated on 2/5/18 regarding procedures for completing treatment plans within appropriate timeframes. Staff was also educated to document barriers to obtaining timely client signatures on treatment plans. The Program Director will monitor adherence through monthly chart audits and results will be reported and monitored through Keystone Center's (parent agency) Performance Improvement Committee. |