INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 26, 2017 by staff from the Division of Drug and Alcohol 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.
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Plan of Correction
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in client records, #4 and 6.
Client #4 was admitted on May 19, 2016 and was discharged on November 2, 2016.
Client #6 was admitted on August 14, 2016 and was discharged on November 7, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be retrained (on 2/16/2017) regarding the timeframes for completion of required paperwork in the client record, including the biopsychosocial summary. Compliance will be verified during monthly chart audits, which will be completed by the program director and clinical managers. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records on January 20, 2017, the facility failed to document a treatment plan update at least every 60 days in client records, #4, and 8.
Client #4 was admitted on May 19, 2016 and discharged on November 2, 2016. The comprehensive treatment plan was completed on June 23, 2016. The treatment plan update was due no later than August 23, 2016. The treatment plan update was documented on October 23, 2017.
Client #8 was admitted on August 1, 2016 and still active at the time of the inspection. The comprehensive treatment plan was completed on September 8, 2016. The treatment plan update was due no later than November 8, 2016. The treatment plan update was documented on January 8, 2017.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff will be retrained (on 2/16/2017) regarding the timeframes for completion of required paperwork in the client record, including treatment plans and related treatment plan updates. Compliance will be verified during monthly chart audits, which will be completed by the program director and clinical managers. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of the client records, the facility failed to provide a physician signature on treatment plans in client records, # 3 and 8.
Client #3 was admitted on September 9, 2016 and active at the time of the inspection. The comprehensive treatment was documented on September 9, 2016.
Client #8 was admitted on August 1, 2016 and active at the time of the inspection. The comprehensive treatment was documented on September 8, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A workflow exists for ensuring that a physician reviews and signs the treatment plans for all individuals funded through medical assistance. All staff will be retrained on this workflow/procedure. Compliance will be verified during monthly chart audits, which will be completed by the program director and clinical managers. |