INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 20-21, 2008 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 21, 2008.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on review of the policy and procedure manual during the inspection on February 4 thru 7, 2008, the facility did not include time frames for the completion of the components of the staff development program.
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Plan of Correction
Project Director shall rewrite the policy and procedure regarding Staff Development Program to include time frames for the completion of the components.
It shall be the responsibility of the Project Director to insure all policy and procedures are accurate and comply with regulations through annual reviews of all policy and procedures.
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on review of the policy and procedure manual and staff interviews during the licensing inspection of February 4 through 7, 2008, the project director failed to remove all of the contradictory policy, procedure and time frames when the manual was updated. The manual contained conflicting policy and procedure for treatment plan updates, medical histories and the psychosocial history/evaluation. One policy statement claims that physical examinations will not be done, while another requires the completion the physical examination form. Staff indicate that the intake and assessment process must be completed within 15 days, but time frames were not provided in the policy and procedure manual.
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Plan of Correction
Project Director shall again review and remove all contradictory policies and procedures and contradictory language throughout the manuals. Project Director will again replace with concise and accurate policies and procedures.
It shall be the responsibility of the Project Director to insure ongoing compliance with this regulation through annual reviews of the policy and procedure manuals.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of the policy and procedure manual and administrative material during the licensing inspection of February 4 through 7, 2008, the annual audit was in draft form for the financial year ending June 30, 2007 and could not be considered complete. The final audit has yet to be completed as of the date of the inspection.
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Plan of Correction
In the future, SPHS Behavioral Health will provide documentation that we meet eligible criteria under the Circular OMB133 or "Single Audit Act" and will be eligible for an extension on the complete final audit.
It shall be the responsibility of the Project Director to insure ongoing compliance with this regulation and insure this audit is completed within the time frames of the Circular OMB133 or "Single Audit Act".
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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 review of client records during the licensing inspection of February 20 and 21, 2008, the project failed to consistently document consent to release information forms that represented informed and voluntary consents. Language regarding re-disclosure of information which would exceed the limitation imposed at 4 Pa. Code Subsection 255.5(b) was documented on the release of information forms, specifically client records, # 2 and 4. In addition, a letter to the Commonwealth of Pennsylvania, Bureau of Disability Determination, constituting a release of information was documented in client record # 7, but no consent to release information signed by the client was documented.
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Plan of Correction
Facility Director has removed all language regarding the redisclosure of information exceeding the parameters of 4 Pa Code Subsection 255.5(b) on the Release of Information Form. Clinical Supervisor will review and train all clinical staff in requirements of obtaining a Release of Information when releasing any information.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart reviews 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.
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Observations
Based on a review of client records during the licensing inspection of February 20 and 21, 2008, the purpose for the release of client identifying information was unclear on release forms in the client records reviewed. The purpose listed was incorrect relative to a third party payer in client record # 3; to a Physician in client record # 4; and to Centralized Case Management in client records # 6 and 7.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff on proper and accurate documentation of the purpose of releasing client information.
It shall be ther responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart reviews and clinical supervision. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on review of client records during the licensing inspection of February 20 and 21, 2008, the facility failed to document a complete personal history. The personal history was missing a complete family, and sexual history in 7 out of 7 client records reviewed, specifically client records # 1, 2 ,3, 4, 5, 6 and 7. The recreational history was not complete in 6 out of 6 client records reviewed, specifically client records # 1, 2, 3, 5, 6 and 7.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff regarding the documentation of complete personal histories, specifically in the areas of family, recreational, and sexual histories.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart review 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 review of the client records during the licensing inspection of February 20 and 21, 2008, the facility failed to document a complete psychosocial evaluation. Psychosocial evaluation failed to consistently document client problem needs in 6 out of 7 client records reviewed, specifically client records # 1, 2, 3, 5, 6 and 7. Negative factors were not consistently documented in 6 out of 7 client records, specifically # 1, 2, 3, 4, 6 and 7.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff on the proper and accurate documentation of complete Psychosocial Evaluations including client problem needs and negative factors.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart reviews and clinical supervision. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
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Observations
Based on review of the client records during the licensing inspection of February 20 and 21, 2008 the facility failed to complete individualized treatment plans in individual treatment sessions. The practice of formulating treatment plans with individual clients during group therapy sessions, and where no individual sessions were documented, does not substantiate the provision of individualized treatment.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff on proper and accurate documentation to reflect that treatment planning is individualized and completed in individual sessions.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart reviews and clinical supervision.
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709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on review of client records during the licensing inspection of February 20 and 21, 2008, the facility failed to document treatment and rehabilitation plans that included short and long term goals that were realistic and stated with measurable criteria. Action plan steps on the treatment plans failed to address what actions and steps the client was to take relative to the issues identified on the client treatment plans. This was evident in seven of seven client records reviewed, specifically client records # 1,2, 3, 4, 5, 6 and 7.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff on treatment and rehabilitation plans, specifically action steps that address how and what the client is to do relative to the issues identified on the client treatment plans.
It shall also be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision.
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709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on review of client records during the licensing inspection of February 20 and 21, 2008, the group progress notes failed to include a complete data, and assessment of the group and failed to demonstrate consistency with the treatment rehabilitation plan objectives. Group notes were incomplete in seven of seven client records reviewed, specifically client records # 1, 2, 3 ,4 5, 6 and 7.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff regarding required elements of a group note including complete data, assessment of the group process, consistency with treatment plan objectives, and all other required elements of a progress/group note.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on review of client records during the licensing inspection of February 20 and 21, 2008, the facility failed to document when the discharge summary was completed. A completion date was not included on the discharge summary, making it impossible to determine if the material was completed in a timely manner. Refer to client records # 5, 6, and 7. In addition client status was not documented in three out of three client records reviewed, specifically client records # 5, 6, and 7.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff regarding the documentation of the date a discharge summary is completed and client status at discharge.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart reviews and clinical supervision.
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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).
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Observations
Based on review of client records during the licensing inspection of February 20 and 21, 2008, the facility failed to document the doctors' signature on the treatment plans.
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Plan of Correction
Facility Director and Medical Director will review with the supervising physician of the facility the need for physician signature on all treatment plans.
It shall be the responsibility of the Clinical Supervisor to insure the ongoing compliance with this regulation through weekly chart reviews and meetings with supervising physician. |