INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 14, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on June 18, 2007.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Staff did not utilize the mechanism to provide feedback for the training attended according to program policy. Documentation was missing for employee # 1.
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Plan of Correction
Communication and paperwork submission is an identified issue between SPHS Behavioral Health and SPHS Inc Human Resource Department. Project Director will submit a reminder memo to all staff regarding the requirement to use the Staff Development and Feedback Form when attending any training and submit to their respective supervisor for submission to the Human Resource Department. Human Resource Director and Project Director will insure ongoing compliance with this regulation through ongoing monitoring of Personnel Records. |
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
Verification of training attended was not documented for employee # 3.
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Plan of Correction
Communication and paperwork submission is an identified issue between SPHS Behavioral Health and SPHS Inc Human Resource Department. Project Director will submit a reminder memo to all staff regarding the requirement of training verification and submit to their respective supervisor for submission to the Human Resource Department. Employee #3 training certificates have been submitted to the Human Resource Department for placement in Personnel File. Human Resource Director and Project Director will insure ongoing compliance with this regulation through ongoing monitoring of Personnel Records. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Alternate exit routes were not documented on the fire drill log.
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Plan of Correction
Clinical Supervisor did not have the use of alternate exit routes clearly documented on the fire drill log.
It shall be the responsibility of the Clinical Supervisor to clearly document alternate exit routes used during monthly fire drills on the fire drill log. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories were incomplete in client record # 8.
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Plan of Correction
Personal histories are completed in reference to the information provided by the client. Staff make all efforts to obtain as much information as possible, however may be limited due to client's unwillingness to provide information at the time of the interview.
It shall be the responsibility of the Clinical Supervisor to review required components of the personal history with clinical staff. In addition, Clinical Supervisor will discuss efforts to obtain as much information as possible and document in the personal history with clinical staff. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance through clinical supervision and weekly chart reviews.
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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
Psychosocial evaluations did not contain complete information. The psychosocial evaluations in client records # 8 and 4 failed to provide for a composite picture and failed to address negative factors that could impact on the recovery effort.
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Plan of Correction
SPHS Behavioral Health makes every effort to assist staff in developing the skills necessary to write sufficient psychosocial evaluations. Writing skills of various staff differ and are regularly reviewed and discussed through clinical supervision and chart reviews.
It shall be the responsibility of the Clinical Supervisor to review and provide examples, indicated during the recent Department of Health Licensing visit as meeting this standard, to clinical staff. Clinical Supervisor will insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews.
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709.83(a)(9) 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:
(9) Progress notes.
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Observations
Group progress notes did not address group interaction or dynamics in the files reviewed. When group sessions are conducted, individual notes need not be written for each client. One group note will suffice provided that it includes a comment relative to each individual's response or participation in the group session and the relationship of that group treatment activity to the individual's treatment plan.
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Plan of Correction
SPHS Behavioral Health chooses to use individual group notes for each participant in group sessions. Group interactions or dynamics for each member need to be better documented.
It shall be the responsibility of the Clinical Supervisor to review and train staff on the group note documentation, including group member's interaction or group dynamics. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews.
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
The manual at the main administrative office contained contradictory policies and procedures. The general organization of the manual made the review difficult and increased the potential for misunderstanding the intent of various procedures. The manual should include policies and procedures that are stated once and are not contradictory and should be organized to permit staff to readily access needed information.
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Plan of Correction
SPHS Behavioral Health will correct all deficiencies and reorganize manuals to meet current manual standards.
It shall be the responsibility of the Project Director and Facility Director to insure the Policy and Procedure Manuals remain in compliance with standards through annual reviews of the manuals. |
709.24(a)(2) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(2) Treatment models utilized by the project.
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Observations
The manual identified a number of different treatment models but did not define each one, choosing only to define the existential model and the criminal personality model. In order to determine that the project is providing client services consistent with the treatment models used, definitions of the specific agency application of each treatment model must be included.
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Plan of Correction
The missing definitions are an oversight on the part of the Facility Director.
Project and Facility Director will include definitions to the various treatment models used by SPHS Behavioral Health. It shall be the responsibility of the Clinical Supervisor to insure clinical documentation is consistent with the models as they are defined through clinical supervision and weekly chart reviews.
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709.26(d)(3) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(3) The verification of training experience and professional licensure or registration, where applicable.
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Observations
Training and experience was not consistently documented in employee files reviewed. Employee # 2 did not have verification of college transcripts in his/her file. Employee # 3 did not have documentation of training attended.
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Plan of Correction
SPHS Behavioral Health and SPHS Inc Human Resource Department are working collaboratively to address the documentation required in Personnel Records.
Project Director will submit a reminder memo to all Clinical Supervisors regarding the required documentation for employment and trainings for Personnel Records and submission to Human Resource Department. Human Resource Director and Project Director will insure ongoing compliance with this regulation through ongoing monitoring of Personnel Records.
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709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
The purpose for the release of client identifying information was unclear on release forms in the client records reviewed. The purpose must identify the reason for the release of information to the person or entity specified.
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Plan of Correction
SPHS Behavioral Health did not provide a logically consistent purpose of the release of information in regards to the function of the entity receiving information.
It shall be the responsibility of the Clinical Supervisor to review and train staff on clearly identifying the purpose of the informed consent and specify a logical and consistent reason for the release in regards to the function of a specific person or entity to insure only required and pertinent information is released. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through clinical supervision and ongoing weekly reviews.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories did not adequately address the areas required in sufficient detail in 5 client records reviewed (1, 3, 5, 6 and 7) . Personal histories should collect as much personal information about a client as possible since they form the basis from which the psychosocial evaluation and subsequent treatment plans are formulated.
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Plan of Correction
SPHS Behavioral Health makes every attempt to obtain as much information regarding personal histories on each client as possible. However we are limited to the information the client is willing to provide to the counselor.
It shall be the responsibility of the Clinical Supervisor to review required components of the personal history with clinical staff. In addition, Clinical Supervisor will discuss efforts to obtain as much information as possible and document in the personal history with clinical staff. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance through clinical supervision and weekly chart reviews.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations in 5 out of 6 client records were incomplete ( Client records # 2, 3, 5, 6 and 7).
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review all required elements of the psychosocial evaluation as defined in regulation, including but not limited to the negative factors and to provide as much detail as possible in order to provide a composite picture. Examples will be provided indicated during the recent Department of Health Licensing visit as meeting this standard to clinical staff. Clinical Supervisor will insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews.
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709.93(a)(5) 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:
(5) Progress notes.
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Observations
Group treatment notes in the client records reviewed failed to include any information about group interactions and dynamics. When group sessions are conducted, individual notes need not be written for each client. One group note will suffice provided that it includes a comment relative to each individuals response or participation in the group treatment session.
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Plan of Correction
SPHS Behavioral Health chooses to use individual group notes for each participant in group sessions. Group interactions or dynamics for each member need to be better documented.
It shall be the responsibility of the Clinical Supervisor to review and train staff on the group note documentation, including group member's interaction or group dynamics. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Follow up was not documented in accordance with agency policy in one of two applicable client records (#7).
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Plan of Correction
The Follow-Up Policy in the manual was inconsistent with the practice of the programs.
Project and Facility Director will rewrite the Follow-Up Policy to accurately reflect that Follow-Up is conducted at 6 months post-treatment. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with the Follow-Up Policy through random supervision of discharged client charts.
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