INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 9, 2012 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)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, CPR and first aid certification cards, the facility failed to ensure that a sufficient number of staff persons were trained in CPR and first aid.
The findings include:
Five personnel records and employee CPR and first aid certification cards were reviewed on February 3 and February 9, 2012. Only one full-time employee has both CPR and first aid certification. If this employee is unavailable to work, the facility does not have any other employees with CPR and first aid certification to provide coverage. The facility failed to ensure that a sufficient number of staff persons were trained in CPR and first aid.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Four additional employees of this facility will be trained in CPR/First Aid.
It shall be the responsibility of the Clinical Supervisor to insure this facility has a sufficient number of staff trained in CPR/First Aid. The Clinical Supervisor will review staff trainings and a quarterly basis.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document the development of an individual treatment and rehabilitation plan with the client, as per facility policy, in three of five outpatient client records.
The findings include:
Fourteen client records were reviewed on February 9, 2012. Ten client records pertained to the outpatient client activity. Five client records were reviewed for individual treatment and rehabilitation plans. Per facility policy, an individual treatment and rehabilitation plan will be developed with the client within 30 days of admission. The facility failed to document the development of an individual treatment and rehabilitation plan with the client in client records # 6, 7 and 8.
Client # 6 was admitted into treatment on November 1, 2011. An individual treatment and rehabilitation plan was due to be completed no later than December 1, 2011. The counselor completed the treatment plan on November 16, 2011. The client did not sign the treatment plan as of February 9, 2012. Per review of the record of services provided, the client was present in treatment during this time period. The facility failed to document the development of an individual treatment plan with the client.
Client # 7 was admitted into treatment on October 20, 2011. An individual treatment and rehabilitation plan was due to be completed no later than November 20, 2011. The counselor completed the treatment plan on November 18, 2011. The client did not sign the treatment plan until November 25, 2011. Per review of the record of services provided, the client was present in treatment during this time period. The facility failed to document the development of an individual treatment plan with the client.
Client # 8 was admitted into treatment on October 6, 2011. An individual treatment and rehabilitation plan was due to be completed no later than November 6, 2011. The counselor completed the treatment plan on November 4, 2011. The client did not sign the treatment plan until November 17, 2011. Per review of the record of services provided, the client was present in treatment during this time period. The facility failed to document the development of an individual treatment plan with the client.
The clinical supervisor was interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
The Clinical Supervisor will review the requirements of appropriate development of an individual treatment plan with clincal staff, namely time frames and review of treatment plan goals with individual clients.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervistion. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation, as per facility policy, in two of five outpatient client records.
The findings include:
Fourteen client records were reviewed on February 9, 2012. Ten client records pertained to the outpatient activity. Five client records were reviewed for case consultations. Per facility policy, a case consultation will be conducted every 90 days. A consultation should include the primary counselor and at least one other clinician. The facility failed to document a case consultation every 90 days in client records # 7 and 8.
Client # 7 was admitted into treatment on October 20, 2011. A case consultation was due to be completed no later than January 20, 2011. A case consultation note was signed by the primary counselor on January 18, 2012. A second counselor signed the case consultation note on January 27, 2012. The narrative of the case consultation note does not indicate the date of the consultation or the names of the persons attending and their disciplines. It is unknown if a case consultation actually occurred between these two clinicians.
Client # 8 was admitted into treatment on October 6, 2011. A case consultation was due to be completed no later than January 6, 2011. A case consultation note was signed by the primary counselor on January 5, 2012. A second counselor signed the case consultation note on January 27, 2012. The narrative of the case consultation note does not indicate the date of the consultation or the names of the persons attending and their discipline. It is unknown if a case consultation actually occurred between these two clinicians.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Clinical Supervisor will review documentation of case consultation, regulated time frames, and appropriate identification of staff involved in case consultation.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision. |