INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 10-14, 2009 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 and a plan of correction is due on September 11, 2009.
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the agency policy and procedure materials and the agency training plan, the facility failed to document an overall agency training plan to address the training needs for the 2009-2010 training year.
The findings included:
Facility training material was reviewed during the onsite inspection of August 10-14, 2009. Agency policy requires that a training plan be documented on a fiscal year basis. The specifics of documentation as spelled out in agency policy required that the plan be documented in a monthly calendar year format for the fiscal year. The calendar presented at the time of the inspection only included dates through the end of June 2009. No training sessions were documented at the time of the inspection on August 11, 2009 for the 2009-2010 training year.
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Plan of Correction
Project Director will establish an overall agency plan to meet agency training needs for FY 2009-2010. It shall be the responsibility of the Project Director to insure the completion of the overall agency training plan on an annual basis. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on the physical plant inspection, the facility failed to ensure that each bathroom was ventilated by an operable window or exhaust fan.
The findings included:
A physical plant inspection was conducted during the onsite licensing inspection of August 13, 2009. The first floor female lavatory did not have a window and the exhaust fan was not in working order.
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Plan of Correction
Clinical Supervisor reported again to landlord the exhaust fan in lavatory is not working on August 31, 2009. Landlord indicated he will fix the exhaust fan quickly. Clinical Supervisor shall insure physical plant standards are met, specifically regarding the exhaust fan in the lavatory, through weekly physical plant reviews and address any issues immediately. |
709.81(b)(5) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of client records and agency policy, the facility failed to follow agency policy regarding obtaining physicals for each client admitted to the partial hospitalization level of care in two of two client records.
The findings included:
Two client records were reviewed during the onsite inspection of August 13, 2009 relative to the partial hospitalization level of care. There was no documentation of a physical examination in client record # 1 & 2. Agency policy stated that each client is to be asked to get a physical examination from their attending physician and return documentation of the examination within 15 days of admission.
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Plan of Correction
Project Director and Facility Director will removed and revised the Policy and Procedure and narrative program description regarding the requirement for Physical examinations for partial hospitalization. It shall be the responsibility of the Project and Facility Directors to insure Policy and Procedures are accurate and appropriate through annual reviews. |
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 the review of client records, the facility failed to document psychosocial evaluations which provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in two of two client records.
The findings included:
Two client records were reviewed during the onsite licensing inspection of August 13, 2009 at the partial hospitalization level of care. Both client records were required to include documentation of a complete psychosocial evaluation. Client records # 1 & 2 did not include documentation of psychosocial evaluations which provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation. The content in the psychosocial evaluations was a reiteration of the client's history rather than a clinical evaluation.
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Plan of Correction
Facility Director and Clinical Supervisor will review and train clinical staff on appropriate completion of psychosocial evaluations and development of a composite picture of the individual, specifically but not limited to, the relationship of all collected information in order to identify possible relationships, conditions and causes leading to the client's current situation.
It shall be the responsibility of the Clinical Supervisor to insure psychosocial evaluations are complete and provide a composite picture through weekly chart and clinical supervision.
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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
Based on the review of client records, the facility failed to document psychosocial evaluations which provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
The findings included:
Six client records were reviewed during the onsite licensing inspection of August 13, 2009 at the outpatient level of care. Five client records were required to include documentation of a complete psychosocial evaluation. Client records # 6 & 7 did not include documentation of available support systems. Client records # 2, 3, 4, 5 and 6 did not include documentation of
psychosocial evaluations which provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
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Plan of Correction
Facility Director and Clinical Supervisor will review and train clinical staff on appropriate completion of psychosocial evaluations and development of a composite picture of the individual, specifically but not limited to, the relationship of all collected information in order to identify possible relationships, conditions and causes leading to the client's current situation and available support systems.
It shall be the responsibility of the Clinical Supervisor to insure psychosocial evaluations are complete and provide a composite picture through weekly chart and clinical supervision
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates in one of two client records.
The findings included :
Eight client records were reviewed at this level of care during the onsite licensing inspection of August 13, 2009. Two of these were required to include documentation of treatment plan updates every sixty days. Client record # 1 did not include documentation of treatment plan updates. The client was admitted on 4/14/09 and discharged on 7/2/09. The comprehensive treatment plan was formulated on 4/23/09. There was no documentation of a treatment plan update in the record at the time of the inspection on August 13, 2009.
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Plan of Correction
Facility Director and Clinical supervisor will review and train clinical staff regarding the requirement to update treatment plans at least every 60 days.
It shall be the responsibility of the Clinical Supervisor to insure psychosocial evaluations are complete and provide a composite picture through weekly chart and clinical supervision
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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 the review of client records during the onsite licensing inspection of August 13, 2009, the facility failed to document quarterly case consultations in each applicable record reviewed.
The findings included:
Eight client records were reviewed during the onsite inspection. One of these was required to include documentation of a case consultation. Client record # 4 documented that the client was admitted on 1/26/09 and discharged on 5/7/09. At the time of the inspection on August 13, 2009 no case consultation was documented in the client record.
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Plan of Correction
Facility Director and Clinical supervisor will review and train clinical staff regarding the requirement of quarterly case consultation.
It shall be the responsibility of the Clinical Supervisor to insure quarterly case consultations are completed and through weekly chart and clinical supervision
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document aftercare plans which documented goals built on progress made in treatment and had timeframes documented for each goal.
The findings included:
During the onsite licensing inspection of August 13, 2009 eight client records were reviewed. Four client records, ( # 1, 3, 4 & 7), were applicable for documentation of an aftercare plan. Client records # 4 & 7 did not include documentation of treatment goals which built on the progress achieved during treatment by incorporating goals which dealt with the client's drug and alcohol abuse issues. Client record # 3 did not have an aftercare plan documented stating that the client had moved and was not available to complete the plan. The policy, however, required that the plan was to be formulated during the last month of treatment. Based on the documentation in the client record there had been ample time to formulate the treatment plan before the client moved. Treatment goals documented in client record # 1 did not identify time frames for each goal.
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Plan of Correction
Facility Director and Clinical Supervisor will review and train clinical staff regarding the appropriate development and documentation of aftercare plans including but not limited to appropriate goals related to treatment progress and time frames for completing aftercare goals. In addition, staff will be trained on the policy to begin developing aftercare plans during the last month of treatment.
It shall be the responsibility of the Clinical Supervisor to insure aftercare plans are completed thoroughly and accurately, when applicable, and through weekly chart and clinical supervision.
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