INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 12, 2013 by staff from the Program Licensure Division. 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:
Six 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 21, 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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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 12, 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 12, 2013 at approximately 9:15 AM. The front entrance door to the facility was observed to have a double keyed deadbolt lock. This lock would prevent the front entrance door 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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