INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 14 - 15, 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 and facility director in two of two personnel records.
The findings include:
Fifteen personnel records were reviewed on February 13, 2013. Two personnel records pertained to the project director and facility director and required documentation of 12 clock hours of annual training. The training year reviewed was from July 1, 2011 through June 30, 2012. The facility failed to document 12 clock hours of annual training for the 2011/2012 training year in personnel records # 1 and 2.
Employee # 1 was hired as the project director on July 1, 1978. Personnel record # 1 did not include documentation of any training hours for the 2011/2012 training year, as of February 13, 2013.
Employee # 2 became the facility director on July 16, 2004. Personnel record # 2 only included documentation of 6 training hours for the 2011/2012 training year, as of February 13, 2013.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Project Director has received 7 hours of training and Facility Director has obtained 12 hours of required training this calendar year.
Project Director will obtain the remaining hours to meet the 12 hours of required training. Project and Facility Director will insure ongoing compliance with this regulation. |
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 two of three personnel records.
The findings include:
Fifteen personnel records were reviewed on February 13, 2013. Three personnel records pertained to counselors and required the completion of 25 clock hours of annual training. The training year reviewed was from July 1, 2011 through June 30, 2012. The facility failed to document 25 clock hours of annual training for the 2011/2012 training year in personnel records # 14 and 15.
Employee # 14 is a counselor and was hired on May 1, 2009. Personnel record # 14 only included documentation of 15 clock hours of annual training for the 2011/2012 training year, as of February 13, 2013.
Employee # 15 is a counselor and was hired on June 16, 2009. Personnel record # 15 only included documentation of 12 clock hours of annual training for the 2011/2012 training year, as of February 13, 2013.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Counselors will be scheduled for the required 25 hours of training through the end of this training year.
It shall be the responsibility of the clinical supervisor to insure ongoing compliance with this regulation through routine reviews of training records for counselors. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the client in two of four partial hospitalization client records.
The finding include:
Seven partial hospitalization client records were reviewed on February 14, 2013. Four client records were reviewed for psychosocial evaluations that included a clinical assessment of the client. The facility failed to document a psychosocial evaluation that included a clinical assessment of the client in client records # 3 and 4.
Client # 3 was admitted into treatment on January 8, 2013. A psychosocial evaluation was completed on October 23, 2012. The psychosocial evaluation did not include a clinical assessment of the client's assets/strengths, support systems and coping mechanisms and only included client reported historical information.
Client # 4 was admitted into treatment on January 7, 2013. A psychosocial evaluation was completed on December 27, 2012. The psychosocial evaluation did not include a clinical assessment of the client's assets/strengths, support systems and coping mechanisms and only included client reported historical information.
The clinical supervisor was interviewed on February 15, 2013 and confirmed the findings.
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Plan of Correction
Clinical Supervisors will review the appropriate completion and documentation of the clinical assessment, client's assets/strengths, support systems, and coping mechanisms in the psychosocial evaluation.
It shall be the responsibility of the clinical supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility's physician failed to document in the patient's record the basis for the determination of current dependency and evidence of a one year history of addiction in one of one patient records.
The findings include:
Twenty-five client records were reviewed on February 14 - 15, 2013. One patient was prescribed Suboxone. This patient record was reviewed for documentation that the physician made a face-to-face determination of whether the individual was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for this determination. The physician failed to document in the patient's record the basis for determination of current dependency and evidence of a one year history of addiction in patient record # 21.
Patient # 21 was admitted into treatment on September 20, 2012. The physician conducted a face-to-face visit with patient # 21 on October 4, 2012. The physician prescribed 8 mg/2 mg Suboxone daily on October 5, 2012. The physician failed to document whether patient # 21 was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for the determination.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and did not dispute the findings.
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Plan of Correction
Facility physician will document the basis for the determination of current dependency and evidence of one year history of addiction.
It shall be the responsibility of the facility physicians to document appropriately. It shall also be the responsibility of the clinical supervisor to insure ongoing compliance with this regulation through weekly chart reviews. |