INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 8, 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 17, 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 of February 8, 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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705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection of the facility during the licensing inspection on February 8, 2008, the facility failed to replace missing ceiling tiles in the group room.
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Plan of Correction
It shall be the responsibility of the Project Director to contact landlord for facility to have ceiling tiles replaced.
It shall be the responsibility of the Clinical Supervisor to notify the Project Director immediately when any Physical Plant issue occurs and to monitor facility on a regular basis for ongoing compliance with all Physical Plant regulations.
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709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. 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 8, 2008, the facility failed to document a complete personal history. The personal history was missing the family history, legal history, recreational history, and sexual history in 1 out of 1 client records reviewed, specifically client record # 4.
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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, legal, educational, 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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709.82(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.
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Observations
Based on review of the client record during the licensing inspection of February 8, 2008, the facility failed to document a complete treatment plan update. The treatment plan update failed to include complete detail of the client's progress in relationship to the stated goals of the comprehensive treatment plan, in one out of one client record reviewed, specifically client record # 4.
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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 the treatment plan update including detail of client's progress in relationship to stated goals in the comprehensive treatment plan.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart review and clinical 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.
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Observations
Based on review of the client record during the licensing inspection of February 8, 2008, the facility failed to document individual counseling at least twice weekly during the weeks of 1/7/08 and 1/21/08 in client record # 4, one of one client record reviewed.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review the required 2 individual sessions and to document sessions with clinical staff.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart reviews and clinical supervision. |
709.83(a)(9) 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:
(9) Progress notes.
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Observations
Based on a review of the client record during the licensing inspection of February 8, 2008, the facility failed to document complete group progress notes. Group progress notes did not address group interaction or dynamics in the one client record reviewed for the partial hospital treatment track, client record #4.
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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 group dynamics or interactions. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision. |
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 8, 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 of 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 8, 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 due to the project not getting all the fiscal information needed to complete the report back until January 2008.
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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)(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 8, 2008, the purpose for the release of client identifying information was unclear on release forms in the client records reviewed. The purpose listed failed to identify the reason for the release of information to the person or entity specified on the consent to release information form in three of three client records reviewed, specifically #2, 3 and 4.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff how to properly and accurately indicate the purpose for the release of client information.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart reviews and clinical supervision. |
709.91(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 8, 2008, the facility failed to document a complete personal history in 3 out of 3 client records reviewed. The personal histories were incomplete in the following areas: family (client record # 1, 2, and 3) , legal (client records # 1 and 2), employment (client record #1), recreational (client record # 1), and sexual (client record # 1, 2, and 3).
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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, legal, employment, 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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709.92(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 8, 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 how and what the client is to do relative to the issues identified on the client treatment plans. This was evident in three of four client records reviewed, specifically client records #1, 2 and 3.
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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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709.92(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.
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Observations
Based on review of client records during the licensing inspection of February 8, 2008, the facility failed to document the client's progress or lack of progress on the treatment plan update. The treatment plan update failed to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in client record #1, one of four client records reviewed but the only record where a treatment plan update was required.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train clinical staff on documentation of assessment of client's progress in relationship to the stated goals of the comprehensive treatment plan.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart reviews and clinical supervision. |
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 on February 8, 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 three of four client records reviewed, specifically client records #1, 2 and 3.
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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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