INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 15, 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 .
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of employee records, the facility failed to ensure that all staff reviewed mandatory TB/STD training within the one year timeframe for clinicians in one of two employee records.
The findings include:
Four employee records were reviewed on January 6 through 7, 2009. Mandatory TB/STD training was required within a one year timeframe in two of two employee records. The facility did not ensure that employees received the mandatory TB/STD training in employee record # 3.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to insure all clinical staff attend the mandatory TB/STD training within one year of hire and provide documentation of training to the human resource department for placement in personnel file. |
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 the review of employee records, the facility failed to maintain client confidentiality within one of four employee records reviewed.
The findings include:
Five employee records were reviewed on January 7 through 8, 2009. The record of employee # 3 contained documentation with full client names written on them.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisors to review and reinforce the Laws Governing Drug and Alcohol Confidentiality with treatment staff, specifically but not limited to, the requirement to have a valid, signed, informed consent to outside parties in order to release pertinent information within the confines of the law. In addition that at no time should a clients' full name be placed on a time sheet at any time. It shall be the responsibility of the Clinical Supervisors to insure ongoing compliance with this regulation through weekly chart and clinical supervision.
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709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the facility failed to document specific information to be disclosed within that allowed by 4 Pa. Code 255.5 in two of six client records.
The findings include:
Nine client records were reviewed on January 15, 2009. Consents to release information were required in six client records. The facility did not appropriately document specific information to be disclosed as there was a consent to release information in client records # 3 from the facility's Prescription Management Program to a third party payor that included physical exam results, medication/RX, urinalysis, treatment recommendations, laboratory results and the treatment plan; client record # 8 contained a consent to release information from the facility's Prescription Management Program to a third party payor that included physical exam results, medication/RX, urinalysis, treatment recommendations, laboratory results and the treatment plan.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisors to review and reinforce the Laws Governing Drug and Alcohol Confidentiality with treatment staff, specifically but not limited to, the specific limitations of information to be released to government entities and third part payors under Pa Code 255.5(b). It shall be the responsibility of the Clinical Supervisors to insure ongoing compliance with this regulation through weekly chart and clinical supervision. |
709.91(a)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(1) Criteria for admission.
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Observations
Based on a review of client records during the onsite licensing inspection of January 15 , 2009 the facility failed to follow established criteria for admission for all clients admitted to this level of care.
The findings included:
Six client records were reviewed during the licensing inspection of January 15 , 2009. Two of these records indicated that the clients were assessed to need services at the partial hospitalization level of care. Client services for this individuals were provided as part of the outpatient activity.
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Plan of Correction
The Clinical Supervisor shall review the criteria for admission with clinical staff and insure all clients are receiving the appropriate level of care based on clinical need. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision and program oversight. |