INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 5 through 9, 2009 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 and a plan of correction is due on February 13, 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 the review of employee records, the facility failed to document training plans in two of two employee records.
The findings include:
Seven employee records were reviewed on January 6 through 7, 2009. Training plans were required to be completed within 30 days for two of two new employees. The facility did not have a training plan for employees # 4 or 6.
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Plan of Correction
It is the policy of this agency to complete initial training plans within 30 days of hire for new employees. The Project Director will issue a memo reminding all management staff and Human Resource staff of this policy. It shall be the responsibility of the respective supervisor or director to insure an initial training plan is completed on new staff within 30 days of hire and submit in a timely fashion to the human resource department. It shall be the responsibility of the Human Resource Director to insure the initial training plans are placed in respective personnel files. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant walk through inspection, the facility failed to insure that there were no heaters that were not permanently mounted or installed.
The findings include:
On January 7, 2009 a physical plant walk through inspection was completed. The facility had two heaters in offices that were not permanently mounted or installed.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisors to insure that heaters which are not permanently mounted or installed are not utilized in the facility. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly monitoring of facility. |
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 the review of client records, the facility failed to document, per their policy manual, weekly multidisciplinary staff meeting notes in four of four client records reviewed.
The findings include:
Eight client records were reviewed on January 7 through 8, 2009. Weekly multidisciplinary staff meeting notes were required in four client records. The facility did not document the multidisciplinary staff meeting notes in client records # 1, 2, 7 and 8.
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Plan of Correction
It is the policy of this agency that Case Consultations occur in a weekly multi-disciplinary staff meeting at least once per quarter. The Project and Facility Director shall rewrite the Policy and Procedure for Case Consultations to more clearly reflect this process. It shall be the responsibility of the Clinical Supervisor to insure case consultations are completed at least once per quarter in the weekly multi-disciplinary staff meeting and documented to accurately reflect this activity. |
709.83(a)(8) 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:
(8) Record of services provided.
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Observations
Based on the review of eight client records and the verbal confirmation of the project and facility directors, the facility failed to document records of service accurately in five of eight client records.
The findings include:
Eight client records were reviewed on January 7 through 8, 2009. Records of service showing ten hours of weekly treatment were required in eight of eight client records based upon the clients' treatment plans. The facility did not document the ten hours the clients were receiving in client records # 2, 3, 4, 7 and 8.
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Plan of Correction
It is the policy of this agency that all services provided within the partial hospitalization program shall be documented on an activity form to accurately reflect at least 10 hours of treatment services per week. It shall be the responsibility of the Facility Director and Clinical Supervisor to review this policy and procedure with clinical staff. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
709.83(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow up in two of three client records.
The findings include:
Eight client records were reviewed on January 7 and 8, 2009. Follow up was required in three of eight client records. the facility did not document follow up in client records # 5 and 8.
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Plan of Correction
It is the policy of this agency that a follow-up letter is sent to all clients discharged from the agency at 6 months of discharge. It shall be the responsibility of the Clinical Supervisor to insure follow-up letters are sent to all clients at 6 months after discharge. The Clinical Supervisor will insure the ongoing compliance of this policy through random checks of discharge charts over 6 months old. |
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 document an informed consent to release information in one of seventeen client records.
The findings include:
Twenty five client records were reviewed on January 7 through 8, 2009. Consents to release information were required in seventeen of twenty five client records reviewed. The facility did not obtain a signed copy of a consent in client record # 12, "client forgot to sign" was in the signature line. The facility still released information to the Westmoreland County Prison Treatment Team. Client record # 5 had a release of information to Excela but no consent to release signed and client record # 6 had a release of information to White Deer Run with no consent to release signed by the client.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisors to review and reinforce the Laws Governing Drug and Alcohol Confidentiality with treatment staff, specifically but not limited to, the requirement to have a valid, signed, informed consent to outside parties in order to release pertinent information within the confines of the law. It shall be the responsibility of the Clinical Supervisors to insure ongoing compliance with this regulation through weekly chart and clinical supervision. |
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 the review of client records, the facility failed to restrict the information released to third party payers and government entities to what is permissible under 4 Pa. Code 255.5. indicate the allowable information to be disclosed in eight of twenty five client records.
The findings include:
Twenty five client records were reviewed on January 7 through 8, 2009. Consents to release were required in eighteen of twenty five client records. The facility failed to restrict the information released to third party payers and government entities to what is permissible under 4 Pa. Code 255.5 in seven of eighteen records reviewed.
Outpatient client record # 8 contained a release from the facility to an insurance company that included physical exam results, medication/Rx, urinalysis, treatment recommendations, laboratory results and the treatment plan.
Outpatient client record # 10 contained a release from the facility the insurance company that include physical exam results, medication/Rx, urinalysis, treatment recommendations, laboratory results and the treatment plan.
Partial hospitalization client record # 1 contained a release from the facility to the Single County Authority that included treatment plans, lab results, physical and urinalysis results.
Partial hospitalization client record # 2 contained a release forms that included releases to probation with treatment plan, medications, Psychosocial Evaluation, discharge summary, and to the insurer, which included treatment plan, medications, Psychosocial Evaluation, urinalysis results, and releases to the Department of Public Welfare and a Judge which included lab results and diagnostic impressions.
Partial hospitalization client record # 3, 4 and 5 contained releases to the Single County Authority which included treatment plan, medications, Psychosocial Evaluation, discharge summary, to the insurer which included treatment plan, medications, Psychosocial Evaluation, urinalysis results, to Department of Public Welfare and a Judge which included lab Results.
Partial hospitalization client record #8 contained a consent to release to the SCA which included treatment plan, medications, Psychosocial Evaluation, discharge summary, to VBH which included treatment plan, medications,Psychosocial Evaluation, urinalysis results, to Department of Public Welfare and a Judge which included lab results and a Pennsylvania Client Placement Criteria form that exceeded 255.5 because it included that the client had a history of cutting.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisors to review and reinforce the Laws Governing Drug and Alcohol Confidentiality with treatment staff, specifically but not limited to, the specific limitations of information to be released to government entities and third part payors under Pa Code 255.5(b). It shall be the responsibility of the Clinical Supervisors to insure ongoing compliance with this regulation through weekly chart and clinical supervision.
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