INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 13 - 14, 2012 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.
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel training records and the Staffing Requirements Facility Summary Report form, the facility failed to provide documentation of communicable disease training in two of three personnel training records.
The findings include:
Ten personnel training records were reviewed on February 3, 2012. Three personnel training records were reviewed for documentation of communicable disease training. The facility failed to provide documentation of HIV/AIDS training in personnel training records # 8 and 10.
Employee # 8 is a counselor and was transferred into drug and alcohol treatment services on October 1, 2010. HIV/AIDS training was due to be completed no later than October 1, 2011. The facility failed to provide documentation of HIV/AIDS training for employee # 8.
Employee # 10 is a support staff and was hired on November 15, 2004. HIV/AIDS training was due to be completed no later than November 15, 2006. The facility failed to provide documentation of HIV/AIDS training for employee # 10.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
|
Plan of Correction
Employee #8 is required to attend HIV Training on June 1, 2012 in Westmoreland County. Employee #10 is the agency Medical Director. A waiver request will be sent to Dept of Health, Division of Drug and Alcohol Program Licensure. If waiver not approved, the agency will have this employee trained per regulation.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through regular reviews of employee training plans. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of fire drill records, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
Fire drill records were reviewed for February 2011 through January 2012 on February 14, 2012. The facility failed to document unannounced fire drills for August, September, October and November of 2011.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
|
Plan of Correction
This agency hired a new Clinical Supervisor on Dec. 16, 2011. The new Clinical Supervisor was instructed by the Facility Director on conducting unannounced Fire Drills monthly and has been doing so.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation by conducting the unnannounced Fire Drills monthly and documenting per regulation. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the client in three of four partial hospitalization client records.
The findings include:
Eighteen client records were reviewed on February 13 - 14, 2012. Seven client records pertained to the partial hospitalization activity. Four client records were reviewed for psychosocial evaluations. The facility failed to document a psychosocial evaluation that included a clinical assessment of the client in client records # 1, 3 and 7.
Client # 1 was admitted into treatment on December 19, 2011. The psychosocial evaluation was completed on November 18, 2011. The psychosocial evaluation did not include a clinical assessment of the client and only included client historical information.
Client # 3 was admitted into treatment on December 19, 2011. The psychosocial evaluation was completed on December 15, 2011. The psychosocial evaluation did not include a clinical assessment of the client and only included client historical information.
Client # 7 was admitted into treatment on November 7, 2011 and discharged on December 21, 2011. The psychosocial evaluation was completed on November 2, 2011. The psychosocial evaluation did not include a clinical assessment of the client and only included client historical information.
The facility director and clinical supervisor were interviewed throughout the licensing process and confirmed the findings.
|
Plan of Correction
Clinical Supervisor will review with both intake and clinical staff the appropriate completion of the psychosocial evaluation, including the clinical assessment of the client.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of client records, the facility failed to document the development of an individual treatment and rehabilitation plan with the client in two of four partial hospitalization client records.
The findings include:
Eighteen client records were reviewed on February 13 - 14, 2012. Seven client records pertained to the partial hospitalization activity. Four client records were reviewed for individual treatment and rehabilitation plans. Per facility policy, an individual treatment and rehabilitation plan will be developed with the client. The facility failed to document the development of an individual treatment and rehabilitation plan with the client in client records # 2 and 7.
Client # 2 was admitted into treatment on January 24, 2012. The counselor completed the individual treatment and rehabilitation plan on February 2, 2012. The client did not sign the treatment plan as of February 14, 2012. Per review of the record of services provided, the client was present in treatment during this time period. The facility failed to document the development of an individual treatment plan with the client.
Client # 7 was admitted into treatment on November 7, 2011. The counselor completed the individual treatment and rehabilitation plan on November 16, 2011. The client did not sign the treatment plan until November 17, 2011. The facility failed to document the development of an individual treatment plan with the client.
The facility director and clinical supervisor were interviewed throughout the licensing process and confirmed the findings.
|
Plan of Correction
Clinical Supervisor has developed a treatment plan training to address the requirement to include clients in development of their treatment plans and within the required time frames for partial hospitalization.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
|
Observations
Based on a review of client records, the facility failed to document a treatment plan update that included an assessment of the client's progress in relationship to the stated treatment plan goals in three of three partial hospitalization client records.
The findings include:
Eighteen client records were reviewed on February 13 - 14, 2012. Seven client records pertained to the partial hospitalization activity. Three client records were reviewed for treatment plan updates. The facility failed to document treatment plan updates that included an assessment of the client's progress in relationship to the stated treatment plan goals in client records # 1, 3 and 7.
Client # 1 was admitted into treatment on December 19, 2011. The individual treatment plan was completed on December 28, 2011. A treatment plan update was completed on January 26, 2012. The treatment plan update did not include an assessment of the client's progress in relationship to the stated treatment plan goals.
Client # 3 was admitted into treatment on December 19, 2011. The individual treatment plan was completed on December 29, 2011. A treatment plan update was completed on January 30, 2012. The treatment plan update did not include an assessment of the client's progress in relationship to the stated treatment plan goals.
Client # 7 was admitted into treatment on November 7, 2011 and discharged on December 21, 2011. The individual treatment plan was completed on November 16, 2011. A treatment plan update was completed on December 19, 2011. The treatment plan update did not include an assessment of the client's progress in relationship to the stated treatment plan goals.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
|
Plan of Correction
Clinical Supervisor shall review the requirement to include an assessment of clients progress on treatment goals in the treatment plan update with clinical staff.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
|
Observations
Based on a review of client records, the facility failed to provide individual counseling, at least twice weekly, in one of three partial hospitalization client records.
The findings include:
Eighteen client records were reviewed on February 13 - 14, 2012. Seven client records pertained to the partial hospitalization activity. Three client records were reviewed for documentation of twice weekly individual counseling sessions. The facility failed to document individual counseling, at least twice weekly, in client record # 7.
Client # 7 was admitted into treatment on November 7, 2011 and discharged on December 21, 2011. The facility failed to provided any individual counseling sessions to client # 7 from November 18 through December 21, 2011. There was no documentation as to whether the client scheduled or cancelled any individual counseling sessions during this time frame.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
|
Plan of Correction
Clinical Supervisor will review the requirement of providing two individual sessions per week with clients enrolled in partial hospitalization with clinical staff. Supervisor will also review the need to indicate if a client has cancelled or no showed their scheduled appointment.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
709.83(a)(4) 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:
(4) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document a case consultation, as per facility policy, in two of two partial hospitalization client records.
The findings include:
Eighteen client records were reviewed on February 13 - 14, 2012. Seven client records pertained to the partial hospitalization activity. Two client records were reviewed for case consultations. Per facility policy, a case consultation will be conducted every 90 days. A consultation should include the primary counselor and at least one other clinician. The facility failed to document a case consultation every 90 days in client records # 1 and 3.
Client # 1 was admitted into treatment on December 19, 2011. A case consultation was due to be completed no later than March 19, 2011. A case consultation note was signed by the primary counselor on December 28, 2011. A second counselor signed the case consultation note on January 3, 2012. The narrative of the case consultation note does not indicate the date of the consultation or the names of the persons attending and their disciplines. It is unknown if a case consultation actually occurred between these two clinicians.
Client # 3 was admitted into treatment on December 19, 2011. A case consultation was due to be completed no later than March 19, 2011. A case consultation note was signed by the primary counselor on December 29, 2011. A second counselor signed the case consultation note on January 3, 2012. The narrative of the case consultation note does not indicate the date of the consultation or the names of the persons attending and their disciplines. It is unknown if a case consultation actually occurred between these two clinicians.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
|
Plan of Correction
Clinical Supervisor shall review the requirement of appropriate documentation of case consultations, including time frames and appropriate signatures to reflect accurate conversations.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision. |
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.
|
Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client for disclosure of information that indicated the purpose of disclosure in three of ten client records.
The findings included:
Eighteen client records were reviewed on February 13 - 14, 2012. Ten client records were reviewed for an informed and voluntary consent from the client; including the purpose of disclosure. The facility failed to obtain an informed and voluntary consent from the client; including the purpose of disclosure in client records # 9, 11 and 12.
Client # 9 was admitted into treatment on September 6, 2011. The facility failed to document the purpose of disclosure on any of the consents to release information contained in client record # 9.
Client # 11 was admitted into treatment on November 17, 2011. The facility failed to documented the purpose of disclosure on any of the consents to release information contained in client record # 11.
Client # 13 was admitted into treatment on September 20, 2011. The facility failed to documented the purpose of disclosure on any of the consents to release information contained in client record # 13.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
|
Plan of Correction
Facility will obtain appropriate Consents to Release Information for Clients # 9, 11, and 13 to reflect the purpose of the consent to release information. Clinical Supervisor will review the appropriate completion of Consent to Release Information, including the purpose of the consent with clinical staff.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
|
Observations
Based on a review of client records, the facility failed to document that copies of client consents were offered to the client in three of ten client records.
The findings include:
Eighteen client records were reviewed on February 13 - 14, 2012. Ten client records were reviewed for consents to release information. The consent to release client information form includes the following statement: "Client accepted or refused a copy of this form - circle one." The facility failed to document that copies of client consents were offered to the client in client records # 9, 11 and 12.
Client # 9 was admitted into treatment on September 6, 2011. There were no consents in client record # 9 that indicated whether the client had accepted or refused a copy of the form.
Client # 11 was admitted into treatment on November 17, 2011. There were no consents in client record # 11 that indicated whether the client had accepted or refused a copy of the form.
Client # 13 was admitted into treatment on September 20, 2011. There were no consents in client record # 13 that indicated whether the client had accepted or refused a copy of the form.
The facility director was interviewed throughout the licensing process and confirmed the findings.
|
Plan of Correction
Clients #9, 11, and 13 will be offered a copy of their Consent to Release Information and appropriate response will be circled on the Consent to Release Form. Clinical Supervisor will review the requirement to indicate appropriately whether the client accepted or refused a copy of the Consent form.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision. |
709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
|
Observations
Based on a review of client records, the physician failed to determine the proper dosage level for the patient.
The findings include:
The physician prescribed Suboxone 8 mg/2 mg SL film, 12 mg daily, one AM and half PM for client # 3 on January 25, 2012.
Suboxone film is not formulated to be cut into smaller doses. Prescriptions need to be for the manufactured quantities of 8 mg/2 mg or 2 mg/.5 mg doses. A 12 mg dose requires one prescription for 8 mg/2 mg film and a second for 2 mg/.5 mg film. A 4 mg dose requires the patient be given two 2 mg/.5 mg doses.
The physician prescribed Suboxone 8 mg/2 mg SL tablet, 12 mg daily, 1 1/2 daily for client # 8 on November 30, 2011. The physician also prescribed Suboxone 8 mg/2 mg tablet, 10 mg daily for client # 8 on February 8, 2012.
Suboxone tablets are not formulated to be cut into smaller doses. Prescriptions need to be for the manufactured quantities of 8 mg/2 mg or 2 mg/.5 mg doses. A 12 mg dose requires one prescription for 8 mg/2 mg tablets and a second for 2 mg/.5 mg tablets. A 4 mg dose requires the patient be given two 2 mg/.5 mg doses. A 10 mg dose requires one prescription for 8 mg/2 mg tablets and a second for 2 mg/.5 mg tablets.
The facility director was interviewed throughout the licensing process and confirmed the findings.
.
|
Plan of Correction
Project and Facility Director will issue a memo to all agency physicians prescribing Suboxone to determine the appropriate dosage level of Suboxone and prescribe accordingly.
Project and Facility Director will attempt to conduct meetings with insurance companies who refuse to pay for multiple doses of Suboxone and require presribing that indicates a "split dose".
It shall be the responsibility of the Clinical Supervisor to review documentation of prescribing practices through weekly chart and clinical supervision. Supervisors will notify Project Director and agency Medical Director with questions about prescribing practices. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the client in four of six outpatient client records.
The findings include:
Eighteen client records were reviewed on February 13 - 14, 2012. Eleven client records pertained to the outpatient activity. Six client records were reviewed for psychosocial evaluations. The facility failed to document a psychosocial evaluation that included a clinical assessment of the client in client records # 8, 9, 10 and 13.
Client # 8 was admitted into treatment on October 4, 2011. The psychosocial evaluation was completed on August 5, 2011. The psychosocial evaluation did not include a clinical assessment of the client and only included client historical information.
Client # 9 was admitted into treatment on September 6, 2011. The psychosocial evaluation was completed on August 12, 2011. The psychosocial evaluation did not include a clinical assessment of the client and only included client historical information.
Client # 10 was admitted into treatment on December 5, 2011. The psychosocial evaluation was completed on November 21, 2011. The psychosocial evaluation did not include a clinical assessment of the client and only included client historical information.
Client # 13 was admitted into treatment on September 20, 2011. The psychosocial evaluation was completed on September 19, 2011. The psychosocial evaluation did not include a clinical assessment of the client and only included client historical information.
The facility director and clinical supervisor were interviewed throughout the licensing process and confirmed the findings.
|
Plan of Correction
Clinical Supervisor will review the appropriate completion of the psychosocial evaluation, including the clinical assessment, with clinical and intake staff.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision. |
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.
|
Observations
Based on a review of client records, the facility failed to document a treatment plan update every 60 days that included an assessment of the client's progress in relationship to the stated treatment plan goals in four of six outpatient client records.
The findings include:
Eighteen client records were reviewed on February 13 - 14, 2012. Eleven client records pertained to the outpatient activity. Six client records were reviewed for treatment plan updates. Per facility policy, treatment plan updates are due to be completed every 60 days. The facility failed to document treatment plan updates every 60 days that included an assessment of the client's progress in relationship to the stated treatment plan goals in client records # 8, 9, 11 and 13.
Client # 8 was transferred into the outpatient activity on October 4, 2011. The individual treatment plan was completed on September 6, 2011. Treatment plan updates were due to be completed no later than November 6, 2011 and January 6, 2012. Treatment plan updates were completed on November 7, 2011 and January 12, 2012. The treatment plan updates did not include an assessment of the client's progress in relationship to the stated treatment plan goals.
Client # 9 was admitted into treatment on September 6, 2011. The individual treatment plan was due no later than October 6, 2011 and was completed late on January 31, 2012. Treatment plan updates were due to be completed no later than December 6, 2011 and February 6, 2012. Two treatment plan updates were both completed on January 31, 2012. The treatment plan updates did not include an assessment of the client's progress in relationship to the stated treatment plan goals.
Client # 11 was admitted into treatment on November 17, 2011. The individual treatment plan was completed on November 17, 2011. A treatment plan update was due to be completed no later than January 17, 2012. A treatment plan update was completed on January 18, 2012. The treatment plan update did not include an assessment of the client's progress in relationship to the stated treatment plan goals.
Client # 13 was admitted into treatment on September 20, 2011. The individual treatment plan was completed on September 28, 2011. Treatment plan updates were due to be completed no later than November 28, 2011 and January 28, 2012. No treatment plan updates were documented for client # 13. A new treatment plan was documented on January 4, 2012.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the licensing inspections conducted on January 31, 2011, March 11, 2010, January 15 - 16, 2009 and February 8, 2008.
|
Plan of Correction
Clinical Supervisor will review the appropriate documentation reflecting an assessment of the client's progress on treatment goals and appropriate time frames for treatment plan updates with clinical staff.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the project failed to assure that individual counseling sessions were provided according to the individual treatment and rehabilitation plan in two of six outpatient client records.
The findings include:
Eighteen client records were reviewed on February 13 - 14, 2012. Eleven client records pertained to the outpatient activity. Six client records were reviewed to assure that counseling services were provided according to the individual treatment plan. The project failed to document that individual counseling sessions were provided according to the treatment plan in client records # 12 and 13.
Client # 12 was admitted into treatment on October 19, 2011. An individual treatment and rehabilitation plan was completed on November 14, 2011. The treatment plan indicated individual counseling sessions would be completed one time per week. No individual counseling sessions were completed from November 21, 2011 through December 26, 2011. There was no documentation as to whether the client scheduled or cancelled any individual counseling sessions during this time frame.
Client # 13 was admitted into treatment on September 20, 2011. An individual treatment and rehabilitation plan was completed on September 28, 2011. The treatment plan indicated individual counseling sessions would be completed one time per week. No individual counseling sessions were completed from October 31, 2011 through January 3, 2012. On January 4, 2012, the treatment plan was updated to indicate individual sessions would be conducted twice per week. No individual counseling sessions were conducted after January 4 through February 14, 2012. There was no documentation as to whether the client scheduled or cancelled any individual counseling sessions during this time frame.
The facility director was interviewed throughout the licensing process and confirmed the findings.
This is a repeat citation from the licensing inspection conducted on January 31, 2011.
|
Plan of Correction
Clinical Supervisor will review the requirement to accurately reflect the modality and frequency of individual therapy on a treatment plan and insuring clients are scheduled as indicated.
It shall be the responsibility of the Clinical Supervisor to insure clients are being scheduled per their treatment plan through weekly chart, clinical, and schedule supervision. |
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.
|
Observations
Based on a review of client records, the facility failed to document a case consultation, as per facility policy, in three of five outpatient client records.
The findings include:
Eighteen client records were reviewed on February 13 - 14, 2012. Eleven client records pertained to the outpatient activity. Five client records were reviewed for case consultations. Per facility policy, a case consultation will be conducted every 90 days. A consultation should include the primary counselor and at least one other clinician. The facility failed to document a case consultation every 90 days in client records # 9, 12 and 13.
Client # 9 was admitted into treatment on September 6, 2011. A case consultation was due to be completed no later than December 6, 2011. Five case consultation notes were signed by the primary counselor on February 7, 2012. The narrative of the case consultation note does not indicate the date of the consultation or the names of the persons attending and their disciplines. It is unknown if a case consultation actually occurred with another clinician on this date.
Client # 12 was admitted into treatment on October 19, 2011. A case consultation was due to be completed no later than January 19, 2012. A case consultation note was signed by the primary counselor on January 12, 2012. The narrative of the case consultation note does not indicate the date of the consultation or the names of the persons attending and their disciplines. It is unknown if a case consultation actually occurred with another clinician on this date.
Client # 13 was admitted into treatment on September 20, 2011. A case consultation was due to be completed no later than December 20, 2011. Three case consultation notes were signed by the primary counselor on February 8, 2012. The narrative of the case consultation note does not indicate the date of the consultation or the names of the persons attending and their disciplines. It is unknown if a case consultation actually occurred with another clinician on this date.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the licensing inspections conducted on January 31, 2011, March 11, 201, and January 15 - 16, 2009.
|
Plan of Correction
Clinical Supervisor will reviwe the appropriate documentation of a case consult and time frame of a case consult with clinical staff.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision. |