INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 27, 2009 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. The following deficiencies were identified during this inspection and a plan of correction is due on May 27, 2009.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel and training records, the facility failed to document an individual training plan to include potential resources for subject areas in five of six records reviewed.
Findings:
Six personnel and training records were reviewed on April 21, 2009. Individual training plans to include potential resources for subject areas were reviewed for six personnel. The facility failed to document potential resources in the training plans for employees #2, 3, 4, 5 and 6.
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Plan of Correction
Human Resource Director will include a list of potential resources to all staff to be included in their annual training plan. The Director of Human Resources will ensure that all staff receive annual training plan. A monthly audit of all personnel files will be conducted to ensure compliance. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on the review of client records, the facility failed to document an assessment of the client's progress in relationship to the stated goals of the prior treatment plan on the treatment plan update in one of three client records reviewed.
Findings:
Three client records were reviewed on April 27, 2009. An assessment of the client's progress in relationship to the stated goals of the prior treatment plan was required in one client record. The facility failed to document an assessment of the client's progress in relationship to the stated goals of the prior treatment plan in client record # 8.
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Plan of Correction
An in-service training for all ambulatory clinicians will be conducted on June 4, 2009 to instruct on the proper protocol for updating treatment plans. This will include the importance of noting the progress of the client in relationship to the stated goals. This will be facilitated by the program director and monitored in the Performance Improvement process monthly by the program director. |
709.83(a)(6) LICENSURE Client records
709.83. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in one of one client record where required.
Findings:
Three client records were reviewed on April 27, 2009. An aftercare plan was required in one client record. The facility failed to document an aftercare plan for client record #8.
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Plan of Correction
The program director will conduct an in-service training on 6/11/09 for all ambulatory staff on the proper completion of aftercare plans for clients completing the program. Compliance will be monitored in monthly Performance Improvement plan by program director.
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709.28(c)(2) 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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in eight of nine client records reviewed.
Findings:
Nine client records were reviewed on April 27, 2009. The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include specific information disclosed in client records #2, 3, 4, 5, 6, 7, 8 and 9. The specific information to be disclosed exceeded Pa Code 255.5 in information to be disclosed to funding sources in client records #2, 3, 4, 5, 6, 7, 8 and 9. The specific information to be disclosed included "aftercare plans". The specific information to be disclosed exceeded Pa Code 255.5 in information to be disclosed to probation in client records #2, 3, 4 and 7. The specific information to be disclosed included "aftercare plans".
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Plan of Correction
An In-service training on Confidentiality and Releases of Information will be conducted by the program director on 6/4/09 for all clinical staff. This training will include the focus on what specifically can and can not be released to outside sources. Program director will monitor compliance with monthly audits as part of the Performance Improvement process. |
709.30(3) LICENSURE Client Rights
709.30. Client rights.
(3) A client has the right to inspect his own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
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Observations
Based on a review of client records and the Patient Handbook Bill of Rights, the facility failed to ensure that the client is aware that he has the right to inspect his own records in seven of nine client records reviewed.
Findings:
Nine client records were reviewed on April 27, 2009. Disclosure to the client of his right to review his own records was required in seven client records. The Patient Bill of Rights, which was signed by each client in client records #1, 2, 3, 4, 5, 7 and 8, stated that the client could review his own records only with the "supervision/approval of the case manager, physician and medical director".
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Plan of Correction
Program director amended the form on client rights changing the language in the handbook to include the client has the right to inspect their own record. Also,the program director can temporarily remove any documentation that may be detrimental to the client and note in a separate location as to the reason for this. This was completed on April 30, 2009. |
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 to include a composite picture, assets/strengths, support systems, attitude toward treatment and/or the counselor's conclusions/impressions in four of six client records reviewed. The facility also failed to document any psychosocial evaluation in one of six client records reviewed.
Findings:
Six client records were reviewed on April 27, 2009. Psychosocial evaluations were required in five client records. The facility did not document a psychosocial evaluation in client records #1, 2, 3, 4 and 5.
The facility did not document a psychosocial evaluation to include the client ' s assets/strengths in client records # 2, 3 and 4.
The facility did not document a psychosocial evaluation to include the client ' s support systems in client records # 2, 3, 4 and 5.
The facility did not document a psychosocial evaluation to include conclusions regarding the client ' s attitude towards and ability to participate in treatment in client records # 2, 3, 4 and 5.
The facility did not document a psychosocial evaluation to include counselor conclusions/impressions in client records #2, 3 and 4.
The facility did not document any psychosocial evaluation in client record #1.
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Plan of Correction
An in-service training on patient psychosocial evaluation will by conducted by the program director on June 11, 2009 for all ambulatory staff. This will focus on inclusion of strengths, assets, utilization of support services and attitude toward treatment. Emphasis on the clinician summarizing their overall impression and conclusions concerning the client is to be included in this training. The full implementation of this will be monitored in the Performance Improvement process by the program director monthly.
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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 the review of client records, the facility failed to document an assessment of the client's progress in relationship to the stated goals of the prior treatment plan on the treatment plan update in four of five client records reviewed.
Findings:
Six client records were reviewed on April 27, 2009. An assessment of the client's progress in relationship to the stated goals of the prior treatment plan was required in five client records. The facility failed to document an assessment of the client's progress in relationship to the stated goals of the prior treatment plan in client records #1, 2, 4 and 5.
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Plan of Correction
In-service training for all ambulatory staff is to be conducted on June 4, 2009 for the proper formulation of treatment plans and updates according to regulation. Particular emphasis will be placed on noting the client's progress in relationship to the specific goals. This will be facilitated by the program director and monitored as part of the monthly PI process by the program director.
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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, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in three of six client records.
Findings:
Six client records were reviewed on April 27, 2009. Counseling services provided according to the individual treatment and rehabilitation plan were required in six client records. The facility failed to document, either in the record of services or progress notes, that counseling services were provided according to the individual treatment and rehabilitation plan in client records #1, 2 and 4.
Group sessions were prescribed one time per week in client record #1. The facility documented group sessions on 1/12, 1/19, 1/26, 2/2, 2/16, 3/15, 3/23 and 3/30/09.
Individual sessions were prescribed one time per month in client record #2. The facility documented no individual sessions. Client #1 was admitted on 12/22/08 and discharged on 3/30/09.
Individual sessions were prescribed one time per week from 10/23/08 until 11/28/08 in client record #4. Individual sessions were prescribed one time per month until discharge date of 2/12/09. The facility did not document any individual sessions.
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Plan of Correction
The in-service training to be conducted on 6/4/09 for all ambulatory staff
will include the importance of providing the specific services identified in the treatment plan and documenting those services particularly in the client record according to regulation. Program director will monitor the compliance of this in the monthly PI process.
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709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to document that counseling was provided to a client on a regular and scheduled basis in two of six client records.
Findings:
Six client records were reviewed on April 27, 2009. Counseling provided to a client on a regular and scheduled basis was required in six client records. The facility failed to document at least one individual session every 60 days for the completion of the comprehensive treatment plan and treatment plan update in client records #1 and 3.
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Plan of Correction
The program director will conduct an in-service for all clinical staff on the importance of providing counseling sessions to develop the master treatment plan with the client. Treatment plan updates should also occur with the client a minimum of every sixty days. These sessions must also be noted on the service record of the respective client. The program director will ensure compliance with this protocol within the Performance Improvement process that occurs monthly. This training is scheduled June 4, 2009. |