INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, SPHS Behavioral Health 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 staff persons received a minimum of 6 hours of HIV/AIDS training in one of one personnel records.
The findings include:
Five personnel records were reviewed on February 19, 2016. One personnel record was reviewed for documentation of HIV/AIDS training. The facility failed to ensure employee # 5 received a minimum of 6 hours of HIV/AIDS training.
Employee # 5 was hired as a counselor on October 1, 2014. HIV/AIDS training was due to completed no later than October 1, 2015. There was no documentation of HIV/AIDS training in personnel record # 5, as of February 19, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will review with supervisor the policy and procedure of ensuring that all staff require the mandatory trainings to meet state regulations. Employee number 5 will be scheduled to attend the 6 hours of HIV/AIDS and 4 hours of TB/STD training. This will occur no later than 6/30/16. The Clinical supervisor will ensure that this staff and any future staff attend mandatory trainings in the appropriate time frames. |
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 a review of client records, the facility failed to obtain a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in five of ten client records.
The findings include:
Ten client records were reviewed on February 19, 2016. Ten client records were required to include documentation of written, informed and voluntary consents from the client. The facility failed to obtain a written, informed and voluntary consent from the client prior to disclosing information contained in the client record in records # 1, 6, 7, 8 and 10.
Client # 1 was admitted into treatment on July 17, 2015. The client's name and insurance information was faxed to a transportation company on July 27, 2015. There was no documentation of a written consent to release information to this transportation company in client record # 1, as of February 19, 2016.
Client # 6 was admitted into treatment on May 11, 2015 and discharged on July 8, 2015. The client's name, diagnosis and request for counseling authorization was faxed to the insurance company on June 23, 2015. There was no documentation of a written consent to release information to this insurance company in client record # 6, as of February 19, 2016.
Client # 7 was admitted into treatment on April 24, 2015 and discharged on July 30, 2015. The client's name, diagnosis and request for counseling authorization was submitted online to the insurance company on June 19, 2015. There was no documentation of a written consent to release information to this insurance company in client record # 7, as of February 19, 2016.
Client # 8 was admitted into treatment on August 25, 2015 and discharged on January 27, 2016. The client's name, diagnosis and request for counseling authorization was submitted online to the insurance company on September 1, 2015. There was no documentation of a written consent to release information to this insurance company in client record # 8, as of February 19, 2016.
Client # 10 was admitted into treatment on June 2, 2015 and discharged on August 17, 2015. The client's name, diagnosis and request for counseling authorization was submitted online to the insurance company on August 17, 2015. There was no documentation of a written consent to release information to this insurance company in client record # 10, as of February 19, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A mandatory staff meeting will be held with all staff to review regulations and guidelines when completing consents to release information. . The clinical supervisor will hold the staff meeting. In addition, staff members who were responsible for charts 1, 6, 7, 8 and 10 will obtain proper consents for those clients where it is appropriate. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor. This will occur no later than 3/31/16. |
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 document a complete client record on an individual which includes information relative to the client's involvement with the project in seven of ten client records.
The findings include:
Ten client records were reviewed on February 19, 2016. Ten client records were reviewed for documentation of a complete client record including case consultation notes and follow-up information. The facility failed to document case consultation notes in client records # 1, 3, 8 and 9. The facility failed to document follow-up information in client records # 6, 7 and 10.
Client # 1 was admitted into treatment on July 17, 2015. There were no case consultation notes documented in client record # 1 from July 17, 2015 through December 31, 2015.
Client # 3 was admitted into treatment on August 26, 2015. There were no case consultation notes documented in client record # 3 from August 26, 2015 through December 31, 2015.
Client # 6 was admitted into treatment on May 11, 2015 and discharged on July 8, 2015. There was no documentation of follow-up information in client record # 6, as of February 19, 2016.
Client # 7 was admitted into treatment on April 24, 2015 and discharged on July 30, 2015. There was no documentation of follow-up information in client record # 7, as of February 19, 2016.
Client # 8 was admitted into treatment on August 25, 2015 and discharged on January 27, 2016. There were no case consultation notes documented in client record # 8 from August 25, 2015 through December 31, 2015.
Client # 9 was admitted into treatment on September 9, 2015 and discharged on January 15, 2016. There were no case consultation notes documented in client record # 9 from September 9, 2015 through December 31, 2015.
Client # 10 was admitted into treatment on June 2, 2015 and discharged on August 17, 2015. There was no documentation of follow-up information in client record # 10, as of February 19, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A mandatory staff meeting will be held with all staff to review case consultation, follow-up, timelines and regulations. This will occur no later than 3/31/16. Each staff member will be provided with a copy of our agency's policy and regulations in regard to case consultation timelines. In addition, staff members who were responsible for charts 1, 3, 8, and 9. will correct these deficiencies no later than 3/31/16 where appropriate. The staff members responsible for client records 6, 7, and 10 will send a follow up letter where appropriate. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor through out the year. |