INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on May 3, 2012, 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:
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of four records.
Findings:
Four personnel records and the facility staffing requirement summary report were reviewed on May 3, 2012. Seven personnel records were required to have documentation of counselor qualifications. The facility failed to provide documentation of counselor qualifications in personnel record # 2.
Personnel record # 2 documented a hire date as 7/27/2011. The counselor did not meet the qualifications for the position of counselor based on a Master of Divinity degree and Bachelor of Arts degree in Political Science. In addition, a review of the Master of Divinity degree course transcripts were reviewed by the Division and were found not to meet the educational component for the position of counselor.
The findings were reviewed with the Facility Director and were not disputed.
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Plan of Correction
Human Resource Director will ensure that the identified Counselor will have his position changed from Counselor to Counselor Aide until he meets the required clinical experience effective 5/18/12. Affected employee hase been given a new job description which has been signed by employee and supervisor to reflect change. Supervision will be initiated by the Facility Director on 6/15/2012. Supervision will be documented by the Facility Director.
Human Resource Director and Facility Director will review credentials of all prospective staff candidates with regard to DOH Staffing Qualifications (CH. 704) to assure proper classification and compliance. Staff whose credentials fail to meet the requirments of Counselor will have his/her job description revised and clinical supervision will be initiated, as well as other steps to ensure compoliance with standard. Results of personnel file audits will be reported by the HR Director to the Performance Improvement Committee. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of the policy and procedure manual and of personnel records, the facility failed to document an assessment of staff training needs.
The findings include:
Four personnel records were reviewed on May 3, 2012, and the policy and procedure manual was reviewed on April 30, 2012, at the main site. Per the facility policy, the assessment forms will be distributed to each employee and the forms will be returned to the Human Resources Director in January. The facility failed to document the completion of a staff training needs assessment in personnel record # 1.
Personnel record # 1 documented a hire date to the current position on March 27, 2011, and hired to the project on June 13, 2005. An assessment of staff needs was not documented at the time of the review.
The findings were reviewed with the Human Resources Director on May 1, 2012 who confirmed the lack of documentation.
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Plan of Correction
Documentation of the assessment of staff training needs in compliance with facility policy will be reviewed by HR Director through a quarterly audit of a sample of personnel files.
Results of audit will be reported to the Performance Improvement Committee by the HR Director.
Any personnel file that does not include an assesssment of staff training needs will have an assessment added. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document an annual evaluation of the overall training plan per the facility policy.
The findings include:
The policy and procedure manual was reviewed on April 30, 2012 at the main site. Facility policy required an annual evaluation of the training plan be completed by the Human Resources director and submitted to the Board of Governors by January 15th of each year. The facility training year is from January through December. The facility documented the annual evaluation of the 2011 training plan was completed by the Human Resources director and presented to the Board of Governors in February 2012.
The findings were reviewed with the Project Director and the Human Resources director on May 2, 2012, and were not disputed.
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Plan of Correction
Human Resources Director will ensure that the annual evaluation of the training plan will be completed and presented to the Board of Governors by January 15th of every year per policy. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice weekly in one of seven records reviewed.
The findings include:
Seven client records were reviewed on May 3, 2012. One client record was reviewed for the partial program. This record was required to document individual counseling at least twice weekly, # 4.
Client record # 4 documented an admission date of December 12, 2011 with a transition to outpatient on January 6, 2012. The client record did not document two individual sessions per week. The weeks of 12/12/2011 and 12/26/2011 had one individual session progress note. The weeks of 12/19/2011 and 1/2/2012 had no individual session progress notes.
The findings were reviewed with the Facility Director and were not disputed.
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Plan of Correction
All Partial Hospitalization patients will participate in a minimum of two individual sessions per week. The individual sessions will be scheduled with oversight by the Facility Director. Evidence of individual sessions will be verified through open and closed chart audits conducted by the Facility Director, with results of the audits reported monthly by the Facility Director to the Performance Improvement Committee. |
709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in one of seven records reviewed.
The findings include:
Seven client records were reviewed on May 3, 2012. One client record was reviewed for the partial program. Per facility policy, case consultations are completed one day prior to transfer level of care, upon significant event in treatment and/or one per treatment episode. The facility did not document a case consultation in client record # 4.
Client record # 4 documented an admission date of December 12, 2011. The client transferred to outpatient treatment on 1/6/2012. A case consultations was not documented.
The findings were reviewed with the Facility Director and were not disputed.
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Plan of Correction
Case Consultation policy will be reviewed by the Facility Director with staff at the 6/11/2012 staff meeting.
Evidence of compliance with policy will be measured through open and closed chart audits, which will be conducted by the Facility Director. The chart audit results will be reported monthly by the Facility Director to the Performance Improvement Committee. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in five of seven client records reviewed.
The findings included:
Seven client records were reviewed May 3, 2012. Five records were reviewed regarding release of information documentation. The facility failed to ensure that an informed and voluntary consent to release information was obtained in five client records reviewed, # 1, 3, 5, 6, and 7.
A review of client record # 1 revealed that a consent to release information to another treatment program was not dated by the client.
A review of patient record # 3 revealed that information was released to a funding entity September 29, 2011. The patient did not sign a release prior to the information release to the funding entity.
A review of patient record # 5 revealed that information was released to a funding entity January 23, 2012. The patient did not sign a release prior to the information release to the funding entity.
A review of patient record # 6 revealed that information was released to a funding entity February 9, 2012. The patient did not sign a release prior to the information release to the funding entity.
A review of patient record # 7 revealed that information was released to a funding entity January 10, 2012. The patient did not sign a release prior to the information release to the funding entity.
The findings were reviewed with the Facility Director and not disputed.
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Plan of Correction
1. Release of Information forms were revised to include releases to applicable funding agencies prior to verification of benefits process.
2. Correct completion of Release of Information forms were reviewed with staff by the Facility Director at the 5/28/2012 staff meeting.
Compliance with Release of Information forms will be verified through open chart audits. Results will be reported monthly to the Performance Improvement Committee. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of client records, the facility failed to document that clients were informed of their rights specified under this section in seven of seven records reviewed.
The findings included:
Seven client records were reviewed on May 3, 2012. All client records were reviewed for client rights. The client handbook contained the client rights and documentation of receipt is indicated by a sign off page. All records contained the sign off document.
The client handbook did not contain notification of the project director temporarily removing portions of the client record prior to the inspection by the client, reasons for removing portions, and the client's right to appeal the decision for removal.
The findings were reviewed with the Facility Director and were not disputed.
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Plan of Correction
The client handbook was revised the day of the inspection so that it contains written notification of the Project Director possessing the authority to temporarily remove portions of the client record prior to the inspection by the client, reasons for removing portions, and the client's right to appeal the decision for removal. This was completed on 5/3/2012 by the Facility Director. The patient handbook is now saved on the Outpatient Public Drive and all future copies will contain this revised language. The public drive is password protected. The hard copies of the Patient Handbook are kept in the chart room. The Patient Handbook is revised as needed by the Facility Director. |
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 clients problems/needs, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in four of seven records reviewed.
The findings include:
Seven client records were reviewed on May 3, 2012. Six client records were reviewed for the outpatient program. The facility failed to provide documentation of a psychosocial evaluation in record # 1, 3, 6 and 7 that included all of the components.
Client record # 1 documented an admission date of February 7, 2012 and discharge date of April 3, 2012. The psychosocial evaluation did not to include a clinical review of the client's coping mechanisms, and negative factors and how they would relate to or impact treatment.
Client record # 3 documented an admission date of September 26, 2011 and discharge date of February 1, 2012. The psychosocial evaluation did not to include a clinical review of the client's support systems, and coping mechanisms and how they would relate to or impact treatment.
Client record # 6 documented an admission date of February 9, 2012. The psychosocial evaluation did not to include a clinical review of the client's problems/needs, support systems, coping mechanisms, and negative factors and how they would relate to or impact treatment.
Client record # 7 documented an admission date of January 10, 2012. The psychosocial evaluation did not to include a clinical review of the client's coping mechanisms and how they would relate to or impact treatment.
The findings were reviewed with the Facility Director and were not disputed.
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Plan of Correction
Facility Director will conduct a training on completion of psychosocial evaluations at the 6/11/2012 staff meeting. The training will include complete documentation of a comprehensive psychosocial evaluation.
Compliance with facility policy will be measured through open and closed chart audits, conducted by the Facility Director and reported monthly to the Performance Improvement Committee by the Facility Director. |
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 review of client records, the facility failed to document treatment plan review and updates within sixty days, in two of seven records.
The findings include:
Seven patient records were reviewed on May 3, 2012. Six records required treatment plan review and updates. The facility failed to document treatment plan review and updates within sixty days, in client records # 2 and 4.
Client record # 2 documented an admission date of February 9, 2012 and discharge date of April 20, 2012. The comprehensive treatment plan was completed on February 23,2012. The first treatment plan update was due no later than April 23, 2012. A treatment plan review and update was developed; however, there was no documentation of the date of completion as the plan was not signed by the client.
Client record # 4 documented an admission date of December 12, 2012 to the partial program, admission to the outpatient program on January 6, 2012, and discharge date of March 12, 2012. The comprehensive treatment plan was completed on December 16, 2011. The first treatment plan update was due no later than February 16, 2012. A treatment plan review and update was completed on February 17, 2012.
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Plan of Correction
Timely Completion of treatment plans and treatment plan updates per facility policy will be reviewed by the Facility Director at the 6/11/2012 staff meeting. Compliance will be verified through open and closed chart audits. Audits will be conducted by the Facility Director. Results of chart audits will be reported by the Facility Director to the Perfomance Improvement Committee on a monthly basis. |