INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 8 , 2009 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 February 13, 2009.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel and training records during the onsite licensing inspection of January 8 , 2009, the facility failed to document an individual training plan for each employee.
The findings included:
Three employee personnel and training records were reviewed during the onsite inspection of January 8 , 2009. Each record was required to document an individual training plan. There was no documentation of individual training plans in employee records #2 and 3.
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Plan of Correction
It is the policy of this agency to complete annual training plans with employees. The Project Director will issue a memo reminding all management staff and Human Resource staff of this policy. It shall be the responsibility of the respective supervisor or director to insure an annual training plan is completed on staff and submit in a timely fashion to the human resource department. It shall be the responsibility of the Human Resource Director to insure the training plans are placed in respective personnel files. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy of counseling sessions in all counseling areas.
The findings included the following:
During the physical plant inspection during the onsite licensing inspection of January 8, 2009, a first floor counseling office was observed to have a door with a large glass window which was not covered which allowed counseling sessions to be observed from outside the counseling area.
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Plan of Correction
It is the responsibility of the Clinical Supervisor to have a blind installed to cover the window of the respective door which can be closed to insure confidentiality and privacy during clinical sessions. It shall be the responsibility of the Clinical Supervisor to insure all physical plant standards are met and in compliance through weekly site monitoring.
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709.81(b)(3)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a complete medical history in one of one client records.
The findings included:
Only one client record was available for review during the onsite licensing inspection of January 8, 2009. This client record was required to have a complete medical history. No family medical history was documented for client record # 1.
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Plan of Correction
It is the policy of this agency that all clients admitted to treatment are to have a completed medical history. It shall be the responsibility of the Clinical Supervisor to review this requirement with clinical staff and to insure ongoing compliance through weekly clinical and chart supervision. |
709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a drug and alcohol history for each client in one of one client records.
The findings included:
Only one client record of the partial hospitalization activity was available for review during the onsite licensing inspection of January 8, 2009. There was no documentation of the drug and alcohol history in client record # 1.
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Plan of Correction
It is the policy of this agency that all clients are to have a complete drug and alcohol history documented in the clinical chart. It shall be the responsibility of the Clinical Supervisor to review this requirement with clinical staff and to insure ongoing compliance through weekly clinical and chart supervision. |
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 a review of client records, the facility failed to document a complete personal history in one of one client records.
The findings included:
Only one client record of the partial hospitalization activity was available for review during the onsite licensing inspection of January 8, 2009. No personal history was documented in client record # 1.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review the requirement to obtain a thorough and complete personal history on all clients. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in one of one client records.
The findings included:
Only one client record was available for review during the onsite licensing inspection of January 8 , 2009. No psychosocial evaluation was documented in client record # 1.
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Plan of Correction
It is the policy of this agency that a psychosocial evaluation be completed on each client. It is the responsibility of the Clinical Supervisor to review the proper clinical completion of the psychosocial evaluation and all elements of it with the clinical staff and 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:
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Observations
Based on a review of client records, the facility failed to document an individualized treatment plan on each client, in accordance with facility policy, in one of one client records.
The findings included:
Only one client record was available for review during the onsite licensing inspection of January 8, 2009 . The treatment plan was not documented within 15 days of admission, as specified in facility policy, in client record # 1.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review the requirement that all clients are to have an individualized preliminary treatment plan within 15 days of admission 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. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document that counseling services were provided according to the individual treatment and rehabilitation plan in one of one client records.
The findings included:
Only one client record was available for review during the onsite licensing inspection of January 8, 2009 The frequency of counseling services provided was not consistent with the frequency listed on the individual treatment plan as documented in client record # 1.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review the required documentation that counseling services were provided according to the individual treatment plan with the clinical staff. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision. |
709.82(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 a review of client records, the facility failed to document the required two individual counseling sessions per week for the partial hospitalization level of care in one of one client records.
The findings included:
Only one client record was available for review during the onsite licensing inspection of January 8, 2009. Individual counseling services were not provided two times per week during the partial hospitalization level of care in client record # 1.
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Plan of Correction
It is the policy of this agency to provide and document two individual sessions per week in partial hospitalization. It shall be the responsibility of the Clinical Supervisor to review this policy with clinical staff and insure ongoing compliance with this regulation through weekly chart and clinical supervision.
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709.83(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record for each client.
The findings included:
Only one client record was available for review during the inspection. Items not documented or incomplete in client record# 1 included the family medical history, personal history, weekly notes as required by facility policy, progress notes and the discharge summary.
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Plan of Correction
It is the policy of this agency that all client records are complete and accurate and shall include, but are not limited to, family medical history, personal history, weekly notes, progress notes, and discharge summary. It shall be the responsibility of the Clinical Supervisor to review this regulation and policy 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. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records the facility did not document a complete medical history and did not document a review of the medical history by the physician on each client in three of five client records
The findings include:
Five client records were reviewed during the onsite licensing inspection held January 8, 2009. Each client record was required to have a complete medical history and to have a review by the physician, as directed by the facility policy regarding medical histories. The physician did not review the medical histories as required by facility policy in client records # 2, 3 and 4.
There was no documentation of a family medical history in client record # 2.
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Plan of Correction
It is the policy of this agency that all clients admitted to treatment are to have a completed medical history, family medical history, and to be reviewed by the facility physician. The Medical Director for the agency will review this requirement with the facility physician. It shall be the responsibility of the Clinical Supervisor to review this requirement with clinical staff and to insure ongoing compliance through weekly clinical and chart 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 the review of the client records, the facility failed to document complete personal histories in five of five client records.
The findings include:
Five client records were reviewed during the onsite licensing inspection held January 8, 2009. Each client record was required to have a complete personal history. Family dynamics were not documented in client records # 3, 4, 5 and 6. Client records # 2, 3, 4 and 5 did not document a complete employment history for each client. Client records # 2, 3, 4 and 5 did not document a complete education history. Client records # 2 and 5 did not document complete sexual histories regarding abuse issues.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review the requirement to obtain a thorough and complete personal history on all clients including but not limited to family relationships and dynamics, employment history, sexual history, and education history. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision. |
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 the review of client records, the facility failed to document complete psychosocial evaluations for each client in five of five client records.
The findings included:
Five client records were reviewed during the onsite licensing inspection of January 8, 2009. Each client records was required to have a complete psychosocial evaluation.
Client record # 6 did not include documentation of a psychosocial evaluation.
Client records # 2, 3, 4 and 5 did not include documentation of client needs.
Client records # 2, 3, 4 and 5 documented strengths/assets from the client's viewpoint only, failing to document the clinician's evaluation of strengths/assets.
Client records # 2, 3, 4 and 5 did not document the clinician's evaluation of coping/defense mechanisms.
Client records # 2, 3 and 5 did not document the clinician's evaluation of negative factors which might impact the client's recovery efforts during the treatment episode.
The clinician's clinical impressions in client records # 2, 3, 4 and 5 did not document interpretations of the collected historical information , how it led to the client's current situation and implications for treatment.
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Plan of Correction
It is the policy of this agency that a psychosocial evaluation be completed on each client. It is the responsibility of the Clinical Supervisor to review the proper clinical completion of the psychosocial evaluation and all elements of it with the clinical staff and to insure ongoing compliance with this regulation through weekly clinical and chart 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 a review of client records, the facility did not document individualized treatment goals on the treatment plans in two of five client records.
The findings included:
Five client records were reviewed during the onsite licensing inspection of January 8, 2009. Each client record was required to have individualized treatment goals on the treatment plans.
Individualized, drug and alcohol specific treatment goals were not documented on the treatment plans in client records # 2 and 5.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review all required elements of the treatment plan, including but not limited to, drug and alcohol specific treatment goals. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical 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.
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Observations
Based on a review of client records, the facility failed to document the provision of treatment services consistent with the type and frequency of treatment specified in the treatment plan.
The findings included:
Five client records were reviewed during the onsite licensing inspection of January 8, 2009. Each client record was required to include documentation of the provision of services in accordance with those specified in the treatment plan. Services provided were not as frequent as stated in the treatment plans in client records # 3, 4 and 6.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review all required elements of the treatment plan, including but not limited to, type and frequency of services, and that services are documented and provided in accordance to treatment plan, with the clinical staff. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision. |
709.93(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.
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Observations
Based on a review of client records, the facility failed to document case consultations as required.
The findings included:
Five client records were reviewed during the onsite licensing inspection of January 8, 2009, one of these records was required to have a documented case consultation. The case consultation was not documented in client record # 6.
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Plan of Correction
It is the policy of this agency that case consultations are to be completed at least once a quarter on each client. It shall be the responsibility of the Clinical Supervisor to review this requirement and proper completion and documentation of case consultations 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 |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document aftercare plans.
The findings included:
Five client records were reviewed during the onsite licensing inspection of January 8, 2009. Two client records in the sample were required to document aftercare plans. No aftercare plans were documented in client records # 2 and 3.
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Plan of Correction
It is the policy of this agency that all clients completing treatment shall have develop an Aftercare Plan with their respective counselor and a copy of this Aftercare Plan be kept in the clinical chart. It is the responsibility of the Clinical Supervisor to review the proper clinical completion of Aftercare Plan documentation with the clinical staff and to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
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 the review of client records, it was determined that the facility failed to document complete discharge summaries in two of three client records.
The findings included:
Five client records were reviewed during the onsite licensing inspection of January 8, 2009. Three records were required to document complete discharge summaries. The discharge summaries in client records # 2 and 4 failed to document the reasons the client appeared for treatment.
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Plan of Correction
It is the policy of this agency that a discharge summary is completed on all clients discharged from treatment for any reason. It shall be the responsibility of the Clinical Supervisor to review the discharge summary and required elements, including but not limited to, reason for treatment with clinical staff. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical supervision and monthly discharge chart reviews. |
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 a review of client records, the facility failed to document a physician signature on each treatment plan and update in clients funded by the Medical Assistance funding stream in two of three client records..
The findings included:
Five client records were reviewed during the onsite licensing inspection of January 8, 2009. Three of these client records were funded by the Medical Assistance funding stream. Client records # 2 and 3 did not have physician signatures documented on the treatment plans and treatment plan updates in those client records.
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Plan of Correction
The Medical Director and Project Director shall review with the facility physician the requirement of physician review and oversight of all treatment plans and to sign all treatment plans per the Medical Assistance regulation. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical supervision and monthly discharge chart reviews. |