INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 27, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, SPHS Behavioral Health - Uniontown 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:
|
Plan of Correction
|
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:
|
Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client prior to disclosure of information in four of eight client records.
The findings included:
Eight client records were reviewed on January 27, 2015. Eight client records were required to document an informed and voluntary consent from the client prior to the disclosure of information. Client records #1, 2, 3 and 6 did not include a valid informed and voluntary consent prior to the disclosure of information.
Client #1 was admitted to treatment on October 14, 2014 and was discharged on January 20, 2015. A release of information, signed on October 14, 2014, to a behavioral health agency did not include specific information to be disclosed, but rather stated "verbal and written communication". A release of information, signed on October 14, 2014, did not include the name to whom the disclosure was made, but rather stated "emergency contact".
Client #2 was admitted to treatment on September 8, 2014 and discharged on December 22, 2014. A release of information, signed on September 14, 2014, to a behavioral health agency did not include specific information to be disclosed, but rather stated "all verbal and written communication".
Client #3 was admitted to treatment on October 6, 2014 and discharged on December 23, 2014. A release of information, signed on October 6, 2014, to a behavioral health agency did not include a date, event or condition upon which the consent will expire. A second release, also signed on October 6, 2014, to a probation office, did not include a date, event or condition upon which the consent will expire.
Client #6 was admitted to treatment on September 14, 2014. A letter was sent to an outside doctor on September 16, 2014; however, there was no consent to release information documented for that doctor contained in the client record.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
A mandatory staff meeting will be held with all staff to review regulations and guidelines when completing consent to release information by the clinical supervisor. This will occur no later than 3/29/15. In addition, staff members who were responsible for charts 1, 2, 3, and 6 will obtain proper consents for those clients where it is appropriate. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
|
Observations
Based on a review of client records, the facility failed to document that clients were informed of their right to retain civil rights and liberties, not be discrmintated on the basis of age , reace, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion, right to inspect their own records, the right to request the correction of inaccurate, irrelevant, out dated or incomplete information and the right to submit rebuttal data in four of eight client records.
The findings include:
Eight client records were reviewed on January 27, 2015. All clients are required to be informed of their rights. The client rights were not disclosed to clients #2, 3, 4 and 6.
Client #2 was admitted on September 8, 2014. At the time of the inspection, there was no signed acknowledgement of client rights in client record #2.
Client #3 was admitted on October 6, 2014. At the time of the inspection, there was no signed acknowledgement of client rights in client record #3.
Client #4 was admitted on October 30, 2014. At the time of the inspection, there was no signed acknowledgement of client rights in client record #4.
Client #6 was admitted on September 4, 2014. At the time of the inspection, there was no signed acknowledgement of client rights in client record #6.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A mandatory staff meeting will be held with all staff to review regulations and guidelines regarding informing our clients of client rights by the clinical supervisor. This will occur no later than 3/29/15. In addition, staff members who were responsible for charts 2, 3, 4, and 6 will obtain documentation of receiving information regarding their client rights for those clients where it is appropriate. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
|
Observations
Based on a review of client records, the facility failed to document the disclosure of the criteria for admission, treatment, completion and discharge to the client in four of eight records.
The findings include:
Eight client records were reviewed on January 27, 2015. All clients are required to be informed of the criteria of admission, treatment, completion and discharge. The criteria for admission, treatment, completion and discharge was not disclosed to clients #2, 3, 4 and 6.
Client #2 was admitted on September 8, 2014. At the time of the inspection, there was no signed acknowledgement of criteria for admission, treatment, completion and discharge contained in client record #2.
Client #3 was admitted on October 6, 2014. At the time of the inspection, there was no signed acknowledgement of criteria for admission, treatment, completion and discharge contained in client record #3.
Client #4 was admitted on October 30, 2014. At the time of the inspection, there was no signed acknowledgement of criteria for admission, treatment, completion and discharge contained in client record #4.
Client #6 was admitted on September 4, 2014. At the time of the inspection, there was no signed acknowledgement of criteria for admission, treatment, completion and discharge contained in client record #6.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A mandatory staff meeting will be held with all staff to review policy and procedure regarding informing our clients of admission, treatment, completion and discharge by the clinical supervisor. This will occur no later than 3/29/15. In addition, staff members who were responsible for charts 2, 3, 4, and 6 will obtain documentation of receiving information regarding of admission, treatment, completion, and discharge for those clients where it is appropriate. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
|
Observations
Based on a review of client records, the facility failed to document client orientation to the project which included project policies, hours of operation, fee schedule and services provided in four of eight client records.
The findings include:
Eight client records were reviewed on January 27, 2015. All clients are required to be oriented to the project which includes project policies, hours of operation, fee schedule and services provided.. The client orientation which included project policies, hours of operation, fee schedule and services provided was not documented in client records #2, 3, 4 and 6.
Client #2 was admitted on September 8, 2014. At the time of the inspection, there was no signed orientation acknowledgement contained in client record #2.
Client #3 was admitted on October 6, 2014. At the time of the inspection, there was no signed orientation acknowledgement contained in client record #3.
Client #4 was admitted on October 30, 2014. At the time of the inspection, there was no signed orientation acknowledgement contained in client record #4.
Client #6 was admitted on September 4, 2014. At the time of the inspection, there was no signed orientation acknowledgement contained in client record #6.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A mandatory staff meeting will be held with all staff to review policy and procedures on the guidelines of orienting clients to the project by the clinical supervisor. This will occur no later than 3/29/15. In addition, staff members who were responsible for charts 2, 3, 4, and 6 will obtain documentation of receiving information regarding orientation to the drug and alcohol program which includes, policy and procedures, hours of operation, fee schedules and services provided. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
|
Observations
Based on a review of client records, the facility failed to document a consent to treatment in four of eight client records.
The findings include:
Eight client records were reviewed on January 27, 2015. A consent to treatment, signed at intake, is required in all client records. Client records # 2, 3, 4 and 6 did not include a signed consent to treatment.
Client #2 was admitted on September 8, 2014. At the time of the inspection, there was no signed consent to treatment contained in client record #2.
Client #3 was admitted on October 6, 2014. At the time of the inspection, there was no signed consent to treatment contained in client record #3.
Client #4 was admitted on October 30, 2014. At the time of the inspection, there was no signed consent to treatment contained in client record #4.
Client #6 was admitted on September 4, 2014. At the time of the inspection, there was no signed consent to treatment contained in client record #6.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A mandatory staff meeting will be held with all staff to review the policy and procedure of obtaining consent for treatment by the clinical supervisor. This will occur no later than 3/29/15. In addition, staff members who were responsible for charts 2, 3, 4, and 6 will obtain consent for treatment for those clients where it is appropriate. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
|
Observations
Based on a review of client records, the facility failed to document a physician signature on the individual treatment plans and updates for medical assistance clients in two of four client records.
The findings included:
Eight client records were reviewed on January 27, 2015. Four of the eight client records reviewed were funded by medical assistnace are required to have a physician signature on the individual treatment plans and updates. The individual treatment plans and updates contained in client records #6 and 7 did not contain a physician signature.
Client #6 was admitted to outpatient treatment on September 4, 2014. The individual treatment and rehabilitation plan and/or updates were documented on October 6, 2014 and December 22, 2014, and did not include a physician signature.
Client #7 was admitted to outpatient treatment on October 21, 2014. The individual treatment and rehabilitation plan and/or updates were documented on November 17, 2014 and November 25, 2014, and did not include a physician signature.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director will review the policy and procedure obtaining physician signatures on individual treatment plans and updates with Clinical supervisor. This will occur no later than 3/29/15. In addition the Clinical supervisor will obtain signatures for chart 6 and 7. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor. |