INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 18 - 19, 2011 and February 2, 2011 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 March 4, 2011.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of staffing requirements facility summary reports and an interview with the facility director, the project failed to provide a full-time clinical supervisor for every eight full-time counselors and counselor assistants.
The findings include:
Six staffing requirements facility summary reports were reviewed on January 18 - 21, 2011. The project consists of six facilities. These six facilities are managed by one facility director. Per regulation, a drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both. As of January 21, 2011, the project has 29.35 full-time counselors and only two full-time clinical supervisors. Three full-time clinical supervisors would be required for 29.35 full-time counselors.
The facility director was interviewed throughout the inspection process from January 18 - 21, 2011. The facility director confirmed that there are only two full-time clinical supervisors for the project.
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Plan of Correction
Project Director and Facility Director will transfer 1 Supervisor to Full-Time Drug and Alcohol Clinical Supervisor position to provide 3 Full-Time Drug and Alcohol Clinical Supervisors for the project to meet this regulation.
It shall be the responsibility of the Project Director and Facility Director to insure there is 1 Full-Time Drug and Alcohol Clinical Supervisor for every 8 Full-Time Equivalent Counselors and Counselor Assistants for this project. It shall also be the responsibility of the Project Director and Facility Director to insure these Full-Time Drug and Alcohol Supervisors have no other duties assigned and ongoing compliance with these regulations through quarterly staffing pattern reviews.
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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 a review of client records, qualified service organization agreements and an interview with the facility director and clinical supervisor, the facility failed to document an informed and voluntary consent or a qualified service organization agreement when releasing urine samples to an outside agency for testing in three of six client records.
The findings include:
Twelve client records were reviewed on February 2, 2011. Urine samples were sent to an outside agency in six client records. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. Client records # 2, 6 and 11 did not include a signed release of information nor was a qualified service organization agreement in place for the outside agency.
Client # 2 was admitted into treatment on November 16, 2010. Urine samples were released to an outside agency without a consent to release information or a qualified service organization agreement on the following dates: November 9 and December 3, 2010.
Client # 6 was admitted into treatment on September 21, 2010. Urine samples were released to an outside agency without a consent to release information or a qualified service organization agreement on the following dates: October 12 and December 7, 2010 and January 13 and January 27, 2011.
Client # 11 was admitted into treatment on March 15, 2010 and discharged on July 13, 2010. Urine samples were released to an outside agency without a consent to release information or a qualified service organization agreement on the following dates: May 18, June 16 and July 13, 2010.
The facility director was interviewed on February 2, 2011 and confirmed the facility had been unable to obtain a qualified service organization agreement with one of the agencies that conducts urine testing. The facility director and clinical supervisor also confirmed that informed and voluntary consents had not been completed for clients # 2, 6 and 11. The facility director reported that staff have been instructed to obtain a consent to release information when utilizing this outside agency.
This is a repeat citation.
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Plan of Correction
Clinical staff will obtain a Release of Information for Clients # 2,6, and 11, for the outside agency that conducts laboratory/urine work for this agency.
It shall be the responsibility of the Clinical Supervisor to review and train staff on the requirement to obtain a release of information for this laboratory facility. It shall also be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision
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