INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 5, 2023 through December 6, 2023 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of eight applicable personnel records reviewed.
Employee # 21 was hired as a maintenance worker on September 1, 2021 and was due to have the HIV/AIDS and TB/STD trainings no later than September 1, 2023. The HIV/AIDS training was completed on November 13, 2023 and the TB/STD training was completed on November 10, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Human Resources was re-educated on monitoring and tracking each employees' required trainings upon new hire and annually. Director of Human Resources will report monthly upcoming staff that are approaching their deadlines as well as any deficiencies found. This will be reported in PI committee monthly. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's February 2023 through October 2023 fire drill logs, the facility failed to ensure the written fire drill log, for the fire drill conducted in August 2023, included which exit route was used.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Interim Director of Plant Operations was immediately re-educated on fully completing the fire drill log forms. Interim Director of Plant Operations will monitor the documentation for completeness and report the compliance monthly within the performance improvement committee. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in two of six applicable client records reviewed.
The facility policy and procedure manual stated treatment plan updates for the inpatient non-hospital activity will be completed every 15 days.
Client # 12 was admitted to the inpatient non-hospital activity on September 25, 2023 and was discharged on November 2, 2023. A treatment plan update was completed on October 10, 2023 and the next update was due no later than October 25, 2023; however, there was no update completed prior to discharge.
Client # 13 was admitted to the inpatient non-hospital activity on October 22, 2023 and was discharged on December 6, 2023. A treatment plan update was completed on November 6, 2023 and the next update was due no later than November 21, 2023; however, there was no update completed prior to discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Primary Therapists were immediately re-educated on timely documentation within the medical record. Ongoing, the Director of Performance Improvement and Director of Clinical Services will monitor and audit 30 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. |
709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on a release of information form in one of fourteen client records reviewed.
Client # 4 was admitted to the inpatient non-hospital detoxification activity on November 28, 2023 and was discharged on December 4, 2023. The release of information form to a government agency was signed and dated by a witness on November 28, 2023, but the release form did not include the dated signature of the client.
This is a repeat citation from the February 15, 2023 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Admissions immediately re-educated all staff in the admissions department the requirement for dated signature by the client on each release of information. Ongoing, the Director of Admissions will monitor and audit 30 charts per month for to each client signatures on the release forms include a date as required. Audit results will be reported through the Performance Improvement Committee monthly. Any deficiencies will be addressed through education and correction action where indicated. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's February 2023 through December 2023 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident at the facility of physical assault involving clients on October 23, 2023.
This is a repeat citation from the February 15, 2023 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services, Director of Risk Management and Director of Quality Assurance were all immediately re-educated of the policy of unusual incidents and DDAP regulation 709.3 (c) (1). Ongoing, Incidents will be reviewed and reported in Keystone Center's daily leadership meeting. Incidents requiring reporting will be identified by leadership and will be reported timely by the Director of Clinical Services, Director of Quality Assurance, or the Director of Risk Management. Compliance with timely incident reporting will be reported monthly through Performance Improvement Committee. |