INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11, 2013 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(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 personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director.
The findings include:
Four personnel records were reviewed on December 5, 2013. One personnel record pertained to the project director and required documentation of 12 clock hours of annual training. The training year reviewed was from July 1, 2012 through June 30, 2013. The facility failed to document 12 clock hours of annual training for the 2012/2013 training year in personnel record # 1.
Employee # 1 was hired as the project director on July 1, 1978. Employee # 1 only had 10 clock hours of annual training documented for the 2012/2013 training year.
The facility director confirmed the findings.
This is a repeat citation from the February 20, 2013 licensing inspection.
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Plan of Correction
The Project Director has completed 6.5 hours of training this training year. The Project Director will complete another 5.5 hours of training to meet the 12 hours of training required per this regulation.
It shall be the responsibility of the Project Director to insure 12 hours of training are obtained each training year
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one personnel records.
The findings include:
Four personnel records were reviewed on December 5, 2013. Two personnel records pertained to counselors. One counselor required the completion of 25 clock hours of annual training. One counselor was a new hire and not yet due to complete annual training hours. The training year reviewed was from July 1, 2012 through June 30, 2013. The facility failed to document 25 clock hours of annual training for the 2012/2013 training year in personnel record # 4.
Employee # 4 is a counselor and was hired on March 21, 2007. Personnel record # 4 only included documentation of 8 clock hours of annual training for the 2012/2013 training year.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the February 20, 2013 licensing inspection.
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Plan of Correction
Clinical Supervisors shall be responsible for insuring clinical staff obtain 25 hours of training in the training year. Facility Director shall review training documentation with Clinical Supervisor to insure all training opportunities, internally and externally, are documented to meet this regulation.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through quarterly reviews of employee trainings.
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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection conducted on December 11, 2013, the facility failed to ensure that exits from the nonresidential facility were unobstructed and operable at all times.
The findings include:
A physical plant inspection was conducted on December 11, 2013 at approximately 9:00 AM. The entrance door to the facility lobby was observed to have a double keyed deadbolt lock. In addition, the emergency exit door at the rear of building has a double keyed deadbolt lock. These locks would prevent these doors from being operable at all times. The facility failed to ensure that exits from the nonresidential facility were unobstructed and operable at all times.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Project and Facility Director will review this regulation with facility landlord to have locks replaced to be unlocked from the inside and provide an unobstructed and operable exit at all times.
It shall be the responsibility of the Clinical Supervisor to insure all exits are unobstructed and operable in the facility at all times.
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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 for the disclosure of client information in one of ten client records.
The findings include:
Ten client records were reviewed for written, informed and voluntary consents from the client on December 11, 2013. The facility failed to obtain a written, informed and voluntary consent from the client prior to releasing information to a funding entity in client record # 3.
Client # 3 was admitted into treatment on April 5, 2013. Client information was disclosed to a funding entity on May 3, 2013 without the written, informed and voluntary consent of client # 3.
The findings were confirmed by the facility director.
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Plan of Correction
Facility has obtained a written, informed and voluntary consent for client #3 for funding entity.
Clinical Supervisor will review with all staff the required written, informed, and voluntary consent for all clients and all entities and individuals needing information. It shall be the responsibility of the Clinical Supervisor to insure compliance with this regulation through weekly chart and clinical supervision. |