INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 13-15th 2019 of UPMC Behavioral Health of the Alleghenies 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, UPMC Behavioral Health of the Alleghenies 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of Twelve clock hours of annual training required for Facility Director in employee #2's employee record.Employee #2 was hired as a counselor on September 1, 1994 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2017 through June 30, 2018 . Employee #2's employee record only documented 7 hours of annual training for the training year reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Tracking of education hours for all D&A staff will be completed by a UPMC BHA Administrative Assistant. D&A staff will turn in all certificates and feedback forms to the Admin Assistant who will enter it onto a spreadsheet weekly.
This spreadsheet of hours completed, certificates turned in and feedback forms completed will be reviewed monthly at D&A staff meetings with the Clinical Services Manager taking the lead to ensure that education is completed per regulations.
This tracking and review at monthly meetings will occur beginning on Wednesday, August 7th.
The facility director will be a part of this process, will complete 12 hours of training annually and attend the monthly D&A staff meeting in which education will occur.
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
The Staffing Requirements Facility Summary Report was completed and reviewed on May 14, 2018. Employee #6 was hired as a counselor on September 11, 2017 and was still acting in that position. Employee #11 was reported to have 20 hours per week devoted to their 21 clients on their caseload.The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by 35. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.The FTE counselor ' s caseload calculation is as follows: 20/35 = .5714(FTE); 21/.5714 = 36.751, which equals to a client/counselor ratio of 37/1. Employee #7 was hired as a counselor on May 18, 2010 and was still acting in that position. Employee #7 was reported to have 3 hours per week devoted to their 6 clients on their caseload.The FTE counselor ' s caseload calculation is as follows: 6/35= .0857(FTE); 6/.0857= 70.011, which equals to a client/counselor ratio of 70/1.
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Plan of Correction
Employee #6 was part time working 3 hours per week and individual to her caseload were added and she did not add hours to her work time in the program.
Employee #11 worked 20 hours in the program and was assigned 21 in the program. This was a mistake on the managers part.
Both of these issues have been corrected and any caseload in D&A will not exceed 35 individuals and casual staff will work 1 hour for every individual on their caseload.
At weekly D&A staff meetings beginning August 7th, caseloads sizes of each counselor will be reviewed along with their hours worked in the program for the past 2 weeks and time scheduled the next week. This will be reviewed, discussed and adjustments needed will be made i.e. re-assigning individuals to other caseloads or increasing scheduled time in program immediately to assure compliance with the requirement.
ADDENDUM July 22, 2019;
We were not utilizing the caseload calculation given to us correctly. This resulted in not having correct caseload ratios for staff not working full time hours.
Employee #6 caseload calculation is as follows; 18/35 = .5714 (FTE); 18/.5714 = 31.5 which equals to a client/counselor ratio of 32/1.
Employee #7 caseload calculation is as follows; 4.5/35 = .129; 4/.129 = 31 which equals to a client/counselor ratio of 31/1.
Caseloads will be reviewed consistently and especially when a client is going to be referred to a counselor who does not work full time in the program. The D&A Program manager will monitor this at assignment, in staff meetings and in individual supervisor using this calculation. |
709.24 (a) (4) 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:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
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Observations
Based on a review of the facility's policy and procedure manual, the project did not have a written procedure for referral outling cooperation with other service providers. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Adult services has completed Procedure #7035 to outline the process for the coordination of all client treatment and rehabilitation services to include cooperation with other service providers. This procedure has reviewed and updated effective July 3, 2019.
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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 must 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 keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in seven client records. Client#1 was admitted on August 10, 2018 and was an active client as of the date of the inspection. A consent to release form was signed and dated on August 10, 2018 to the county funding source that allowed for the release of discharge summary, other-"incident report", meidcal history and phsyical exams, medication records, phsyican orders,psychiatric/psychological eval and progress notes. Client#2 was admitted on October 22, 2019 and was an active client as of the date of the inspection. A consent to release form was signed and dated on October 22, 2019 to the funding source that allowed for the release of discharge summary, other-"incident report", meidcal history and phsyical exams, medication records, phsyican orders, psychiatric/psychological evaluation and progress notes. Client#3 was admitted on November 20, 2017 and was an active client as of the date of the inspection. A consent to release form was signed and dated on November 20, 2018 to the funding source that allowed for the release of discharge summary, other-"incident report", meidcal history and phsyical exams, medication records, phsyican orders, psychiatric/psychological evaluation and progress notes. Client#4 was admitted on October 15, 2019 and was an active client as of the date of the inspection. A consent to release form was signed and dated on October 15, 2019 to the funding source that allowed for the release of discharge summary, other-"incident report", meidcal history and phsyical exams, medication records, phsyican orders, psychiatric/psychological evaluation and progress notes. Client#5 was admitted on March 23, 2018 and was discharged on February 5, 2019. A consent to release form was signed and dated on March 23, 2018 to the funding source that allowed for the release of discharge summary, other-"incident report", meidcal history and phsyical exams, medication records, phsyican orders, psychiatric/psychological evaluation and progress notes. Client#6 was admitted on July 10, 2018 and was discharged on January 4, 2019 . A consent to release form was signed and dated on July 10, 2018 to the funding source that allowed for the release of discharge summary, other-"incident report", meidcal history and phsyical exams, medication records, phsyican orders, psychiatric/psychological evaluation and progress notes. Client#7 was admitted on December 24, 2018 and was discharged on February 14, 2019. A consent to release form was signed and dated on December 24, 2019 to the funding source that allowed for the release of discharge summary, other-"incident report", meidcal history and phsyical exams, medication records, phsyican orders, psychiatric/psychological evaluation and progress notes. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
For clients #1-#7, since no information had actually been released but release forms allowed with wording for the "potential" too release more than PA Code 255.5 allows the authorization to release form will be replaced with a new form developed by the Compliance Manager by 6/4/2019.
The Medical Records Supervisor will train D&A staff on the new release of information form and the updated procedure #6010 Release of Drug and Alcohol Information by 7/1/2019.
Addendum: As of July 1, 2019 the new release was distributed and education of staff on the release form and how to correctly complete as well as PA Code 255.5 interpretation was completed by The Medical Records Supervisor, The Compliance Manager and the Clinical Services Manager.The new release form clearly identifies and has hardcoded in the 5 points allowed by PA Code 255.5 All releases are processed through the medical records department and they do not release to government entities anymore than PA Code 255.5 allows. This is continually monitored through medical records. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of seven client records, the facility's client rights policy failed to include documentation of all the required client rights, including The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. These findings were reviewed with facility staff during the licensing process
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Plan of Correction
UPMC Policy HS-MR-1000 Release of Protected Healthcare Information dated April 2018 and UPMC Behavioral Health of the Alleghenies Procedure 1500.01 Clinical Records: Review or Copy both identify the clients right not to be discriminated in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, martial status, sexual orientation, handicap and religion.
On 6/4/2019 the words "creed and marital status" were added to the BH Individuals Bill of Rights, by the Compliance Manager Form 784. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical 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 in the record.
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Observations
Based on a review of seven client records, the facility's client rights policy failed to include documentation of all the required client rights, including clients have the right to inspect their own records. The project, facility or clinical 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 in the record.These findings were reviewed with facility staff during the licensing process
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Plan of Correction
On 6/4/2019 the Compliance Manager added to procedure 1500.01 the statement that project, facility or clinical director must document if they may have removed parts of a record which may have been temporarily removed prior to clients inspection of the record.
Addendum: The UPMC Policy HS MR 1000 Release of Protected HealthCare Information and UPMC Behavioral health of the Alleghenies Procedure 1500.01 Clinical Records Review or Copy; both identify the clients right to inspect their own record. The project, facility or clinical 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 in the record.The statement was added to the clients bill of rights on 6/4/19 by the Compliance Manager and distributed for use in the intake packets so all clients will receive and sign off on their bill of rights and all previous bill of rights have been discarded.
ADDENDUM July 22, 2019;
BHA will ensure this deficiency does not occur again since the Bill of Rights was updated on 6-4-19 and all other documents were destroyed. The Compliance Manager will conduct monthly reviews of the Bill of Rights document for the next 4 months, starting 8-1-19 to endure that individuals are signing the correct version, that includes the individual's ability to inspect their own records. Then it will move to quarterly reviews starting January 2020.
Over the next 4 months, starting 8-1-19, the Program Supervisor will review al intake packets to ensure the correct Bill of Rights document, that includes the individual's ability to inspect their own records, is being utilized at intake/assessment. Then move to quarterly reviews starting January 2020. Both the Compliance Manager and the Program Supervisor will document the monthly and quarterly reviews to ensure compliance.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of seven client records, the facility's client rights policy failed to include documentation of all the required client rights, including that Clients have the right to appeal a decision limiting access to their records to the director. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance manager will add the clients right to appeal a decision limiting access to their records to the director to procedure 1500.01 by 6/4/19.
Addendum: The UPMC Policy HS MR 1000 Release of Protected HealthCare Information and UPMC Behavioral health of the Alleghenies Procedure 1500.01 Clinical Records Review or Copy; both identify the clients right to appeal a decision limiting access to their records to the director. The statement was added to the clients bill of rights on 6/4/19 by the Compliance Manager and distributed for use in the intake packets so all clients will receive and sign off on their bill of rights and all previous bill of rights have been discarded.
ADDENDUM July 22, 2019;
BHA will ensure this deficiency does not occur again since the Bill of Rights was updated on 6-4-19 and all other documents were destroyed. Compliance Manager will conduct monthly reviews of the Bill of Rights document for the next 4 months, starting 8-1-19 and then conduct quarterly reviews starting January 2020.
Over the next 4 months, starting 8-1-19, the Program Supervisor will review all intake packets to ensure the correct Bill of Rights is being used at intake/assessment. Then move to quarterly reviews starting January 2020.
Both the Compliance Manager and Program Supervisor will document the monthly and quarterly reviews to ensure compliance. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of seven client records, the facility's client rights policy failed to include documentation of all the required client rights, including that Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Manager added to procedure 1500.00 the clients right to request a correction of inaccurate, irrelevant, outdated or incomplete information in their records, by 6/4/19.
Addendum: The UPMC Policy HS MR 1000 Release of Protected HealthCare Information and UPMC Behavioral health of the Alleghenies Procedure 1500.01 Clinical Records Review or Copy; both identify the clients right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
The statement was added to the clients bill of rights on 6/4/19 by the Compliance Manager and distributed for use in the intake packets so all clients will receive and sign off on their bill of rights and all previous bill of rights have been discarded
ADDENDUM July 22, 2019;
Compliance Manager will conduct monthly reviews of the Client Rights document for the next 4 months starting 8-1-19. The Program Supervisor will review all intake/assessment packets to ensure the correct Client Rights document is being used at intake/assessment. Then move to quarterly reviews starting January 2020. The Compliance Manager and Program Supervisor will document the monthly and quarterly reviews to ensure compliance.
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709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of seven client records, the facility's client rights policy failed to include documentation of all the required client rights, including that Clients have the right to submit rebuttal data or memoranda to their own records.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Manager added the statement the clients right to submit rebuttal data or memoranda to their own records to procedure 1500.00. Addendum: The UPMC Policy HS MR 1000 Release of Protected HealthCare Information and UPMC Behavioral health of the Alleghenies Procedure 1500.01 Clinical Records Review or Copy; both identify the clients right to submit rebuttal data or memoranda to their own records.
The statement was added to the clients bill of rights on 6/4/19 by the Compliance Manager and distributed for use in the intake packets so all clients will receive and sign off on their bill of rights and all previous bill of rights have been discarded
ADDENDUM July 22, 2019;
Compliance Manager will conduct monthly reviews of the Client Rights document to ensure that it includes the individual's ability to submit rebuttal data or memoranda to their own records for the next 4 months starting 8-1-9 and then conduct quarterly reviews starting January 2020. Over the next 4 months, starting 8-1-19, the Program Supervisor will review all intake/assessment packets to ensure that it does include the individual's ability to submit rebuttal data or memoranda to their own records. Then move to quarterly reviews starting January 2020.
The Compliance Manger and Program Supervisor will document the monthly and quarterly reviews to ensure compliance.
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709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the facility's policy and procedure manual, the facility does not have a policy and procedureto respond to the Selling or use of illicit drugs on the premises. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Manager, on 6/4/19, added to Procedure 1400.21 the Reporting of Unusual Incidents to PA Dept of D&A the event of needing to report and respond to the selling of illicit drugs on the premises as a reportable offense.
All D&A staff will be reeducated on the procedure by 8/7/2019 by the Clinical Services Manager.
Addendum: ON 8/7/19 Clinical Services manager provided D&A education that included timeframes for DDAP Reporting and that any/all staff are responsible for reporting. This education is given yearly by Compliance Manager as well.
Safety Officer conducts daily rounds and leads emergency disaster plans. He educates all staff regularly at all staff meetings and all new hires. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of the facility's policy and procedure manual, the facility does not have a policy and procedure to respond to significant disruption due to a disaster such as a fire, storm, flood or other occurance which closes the facility for more than 1 day. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/4/19 The Compliance Manager added to Procedure 1400.02 the reporting of significant disruption of services due to disaster such as fire, storm, flood, or other occurrence which closes the facility for more than 1 day.
All D&A Staff will be educated on the reporting procedure by 8/1/19 by the Clinical Services Manager.
Addendum: ON 8/7/19 Clinical Services manager provided D&A education that included timeframes for DDAP Reporting and that any/all staff are responsible for reporting. This education is given yearly by Compliance Manager as well.
Safety Officer conducts daily rounds and leads emergency disaster plans. He educates all staff regularly at all staff meetings and all new hires
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709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the facility's policy and procedure manual, the facility does not have a policy and procedure to respond to theft, burglary, break-in or similar incident at the facility. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
on 6/4/2019 The Compliance Manager created procedure 1400.21 The reporting of unusual incidents to PA Dept of D&A the need to report theft, burglary, break in or similar incident at the facility.
All D&A staff will be educated on the new procedure by the Clinical Services Manager by 8/7/2019.
Addendum: ON 8/7/19 Clinical Services manager provided D&A education that included timeframes for DDAP Reporting and that any/all staff are responsible for reporting. This education is given yearly by Compliance Manager as well.
Safety Officer conducts daily rounds and leads emergency disaster plans. He educates all staff regularly at all staff meetings and all new hires
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709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the facility's policy and procedure manual, the facility does not have a policy and procedure to respond to fire or structural damage to the facility. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/4/2019 The Compliance Manager created procedure 1400.21 The reporting of unusual incidents to PA Dept of D&A the need to include structural damage to facility.
All D&A staff will be educated on the new procedure as well as the Agency's Emergency Operation Plan so staff are aware of what to do in the event of work stoppage by the Clinical Services Manager by 8/7/2019.
Addendum: ON 8/7/19 Clinical Services manager provided D&A education that included timeframes for DDAP Reporting and that any/all staff are responsible for reporting. This education is given yearly by Compliance Manager as well.
Safety Officer conducts daily rounds and leads emergency disaster plans. He educates all staff regularly at all staff meetings and all new hires
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709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the facility's policy and procedure manual, the facility does not have a policy and procedure to respond to Outbreak of a contagious disease requiring Center for Disease Control(CDC) notification.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/4/2019 The Compliance Manager created procedure 1400.21 The reporting of unusual incidents to PA Dept of D&A the need to include the outbreak of disease requiring CDC notification.
All D&A staff will be educated on the new procedure by the Clinical Services Manager by 8/7/19.
Addendum: ON 8/7/19 Clinical Services manager provided D&A education that included timeframes for DDAP Reporting and that any/all staff are responsible for reporting. This education is given yearly by Compliance Manager as well.
Safety Officer conducts daily rounds and leads emergency disaster plans. He educates all staff regularly at all staff meetings and all new hires |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on a review of the facility's policy and procedure manual, the facility does not have a policy and procedure for implementation of a timely and appropiate corrective action plan, when indicated. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/4/2019 The Compliance Manager created procedure 1400.21 The reporting of unusual incidents to PA Dept of D&A the need to include the implementation of a timely and appropriate corrective action plan.
All D&A staff will be educated on the new procedure by the Clinical Services Manager by 8/7/19.
Addendum: ON 8/7/19 Clinical Services manager provided D&A education that included timeframes for DDAP Reporting and that any/all staff are responsible for reporting. This education is given yearly by Compliance Manager as well.
Safety Officer conducts daily rounds and leads emergency disaster plans. He educates all staff regularly at all staff meetings and all new hires |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of the facility's policy and procedure manual, the facility does not have a policy and procedure for ongoing monitioring of the corrective action plan. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/4/2019 The Compliance Manager created procedure 1400.21 The reporting of unusual incidents to PA Dept of D&A the need to include the ongoing monitoring of any corrective action plans.
All D&A staff will be educated on the new procedure by the Clinical Services Manager by 8/7/19.
Addendum: Effective 8/5/19, the Clinical Services Manager is responsible for the overall monitoring of the corrective action plan(s) on a monthly basis. The Clinical Services Manger will report to Compliance Manager, Program Director, and Executive Director monthly. The Compliance Manager will provide education to all staff throughout the year. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
Based on a review of the facility's policy and procedure manual, the facility does not have a policy and procedure for reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with state and federal confidentiality laws. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/4/2019 The Compliance Manager created procedure 1400.21 The reporting of unusual incidents to PA Dept of D&A the need to include instructions on how reporting mechanism ensures the reporting of an unusual incident to an entity is in compliance with the state and federal confidentiality laws.
All D&A staff will be educated on the new procedure by the Clinical Services Manager by 8/7/19.
Addendum:Effective 8/5/19, the Compliance Manager is responsible for the overall monitoring of the reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with state and federal confidentiality laws, as incidents are reported. The Compliance Manager provides quarterly reports to UPMC Corporate Compliance Department. |
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 a review of seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in four client records reviewed.Client #1 was admitted on August 10, 2018 and was still active at the time of the inspection. The comphrensive treatment plan was completed on August 21, 2018 and the next update was due no later than October 21, 2019 ; however, there was no update documented in the record until November 20, 2018.Client #2 was admitted on October 22, 2018 and was still active at the time of the inspection. The comphrensive treatment plan was completed on November 5, 2018 and the next update was due no later than January 5, 2019 ; however, there was no update documented in the record until January 22, 2019.Client #3 was admitted on November 20, 2017 and was still active at the time of the inspection. A treatment plan update was completed on November 21, 2018 and the next update was due no later than January 21, 2019 ; however, there was no update documented in the record until April 26, 2019.Client #4 was admitted on October 15, 2018 and was still active at the time of the inspection. A treatment plan update was completed on February 21, 2018 and the next update was due no later than April 21, 2019 ; however, there was no update documented in the record at the time of inspection.Client #5 was admitted on March 23, 2018 and was discharged on February 5, 2019. A treatment plan update was completed on August 17, 2018 and the next update was due no later than October 17, 2018 ; however, there was no update documented in the record at the time of inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Services Manager reviewed Treatment Plan Policy #6006 with D&A staff on June 12, 2019. The Clinical Services Manager provided education to all D&A staff that the treatment plan must be reviewed with the individual and updated every 60 days. Meeting minutes were taken of the education.
Staff were given a copy of the procedure for their use. This requirement will also be reviewed during supervision and team meetings monthly beginning in August 2019.
Clinical Services Manager will complete random chart reviews of at least 10 charts per month and audit for timely treatment plan updates. |
709.93(a) LICENSURE Client records
709.93. 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:
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a complete record of service in client record#'s 1, 2, 3, 4, and 5. Client #1 was admitted on August 10, 2018 and was still active at the time of inspection. The client record did not contain documentation of a complete record of service past the date of October 10, 2018. Client #2 was admitted on October 22, 2018 and was still active at the time of insepction. The client record did not contain documentation of a complete record of service past the date of March 14, 2019.Client #3 was admitted on November 20, 2017 and was still active at the time of insepctionThe client record did not contain documentation of a complete record of service past the date of January 19, 2018. Client #4 was admitted on October 15, 2018 and was still active at the time of insepction. The client record did not contain documentation of a complete record of service past the date of December 14, 2018. Client #5 was admitted on March 23, 2018 and was still active at the time of inspection. The client record did not contain documentation of a complete record of service past the date of December 4, 2018. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This deficiency was corrected with Procedure 6009 and all D&A staff have been educated on this but there will be formal re-education on August 7th at the weekly D&A staff meeting. Staff have been printing Records of Service regularly since May to place in the clinical file. Files have been caught up with Records of Service in them.
Procedure 6009 has been revised to state that at minimum, the Record of Service is to be printed once per month at the end of the month and placed in filing for the clinical filing. This printing at the end of the month, is the minimum, but these can be printed more frequently and must be printed at discharge.
The Record of Service will be added to the monthly chart audit tool and the Manager will be auditing 10 charts per month to ensure that there is a Record of Service in the clinical file.
The Manager will follow up with staff if the Record of Service is not found in the clinical file to ensure compliance immediately. This audit will occur beginning with July clinical file reviews which will take place by August 30 by the Manager. |