INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 12-13, 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.
|
Plan of Correction
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
Based on a review of personnel and training records during the onsite licensing inspection of January 12-13 , 2009, the facility failed to ensure that each counselor met one of the requirements of this Chapter for employment as a counselor.
The findings included:
Four employee records were reviewed at this facility. Employee #4 did not have a Human Service related degree from an accredited institution of higher education and, consequently, did not meet the requirements for the position of counselor.
|
Plan of Correction
Through discussion with Drug and Alcohol Program Licensing staff and our Human Resource Department, the agency now has a list of accreditation bodies to insure degrees are from accredited universities or colleges. It shall be the responsibility of the Project and Facility Directors to insure all individuals hired have degrees related to human services from accredited institutions. The Project Director shall review every official transcript on all new hires to insure ongoing compliance with this regulation. |
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.
|
Observations
Based on a review of personnel and training records during the onsite licensing inspection of January 12-13 , 2009 the facility failed to ensure that each counselor had documentation of an individual training plan.
The findings included:
Four employee records were reviewed at this facility. Each employee must have a documented individual training plan within one month of the hire date. Employee #2 did not have documentation of an individual training plan. This employee was hired in July of 2008.
|
Plan of Correction
It is the policy of this agency to complete initial training plans within 30 days of hire for new 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 initial training plan is completed on new staff within 30 days of hire and submit in a timely fashion to the human resource department. It shall be the responsibility of the Human Resource Director to insure the initial training plans are placed in respective personnel files. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on a review of administrative census records and agency self reporting on the staffing forms provided by the Division during the onsite licensing inspection of January 12-13 , 2009 the facility failed to ensure that each caseload did not exceed a ratio of 35 to 1.
The findings included:
Two counselors were assigned caseloads at the outpatient level of care. Employee #4 was not qualified for the position of counselor, but was assigned 39 active clients. The second counselor was assigned a caseload of 56 clients. Since employee #4 was not qualified for the counselor position, her hours could not be counted, resulting in an overall caseload of 95:1.
|
Plan of Correction
It is the policy of this agency that outpatient counselor caseloads shall not exceed 35 patients to comply with this regulation. One Caseload exceeded regulation due to recent staff turnover. The agency has since hired 1.8 FTEs to insure caseloads are in compliance with the 1:35 ratio. It shall be the responsibility of the Clinical Supervisor to insure caseloads remain in compliance through weekly caseload monitoring. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of fire drill records, the facility failed to document the use of alternate exits during 2008.
The findings included:
The fire drill documentation log was reviewed for the 12 month period ending in December 2008 during the onsite licensing inspection of January 12-13 , 2009. Exit routes used during the drills were documented but no alternate exit was used during the course of the year. All drills utilized the same exit throughout the year.
|
Plan of Correction
It shall be the responsibility of the Clinical Supervisor, when conducting monthly Fire Drills, that alternative exits are used and documented. It shall be the responsibility of the Clinical Supervisor to insure fire drills occur monthly and are documented accurately and include the use of alternate exits. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on a review of fire drill documentation records, the facility failed to ensure the fire alarm system was in working order during 2008.
The findings included:
A letter from the Division approving use of an alternative procedure to setting off the fire alarm system was on file. The letter specified that documentation must be provided annually to demonstrate that the alarm system was tested and in working order. No documentation was presented during the onsite licensing inspection of January 12-13 , 2009, to demonstrate that the alarm system was tested and in working order for calendar year 2008.
|
Plan of Correction
It shall be the responsibility of the Facility Director and Clinical Supervisor to insure that documentation is on file that annual fire alarm tests are conducted and results of test are available for review. |
709.82(d) 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:
|
Observations
Based on a review of client records, the facility failed to ensure that individual counseling sessions were conducted twice per week as required at this level of care in three of three client records.
The findings included:
Three client records were reviewed during the onsite licensing inspection of January 12-13, 2009. Each client record was required to have documentation of individual counseling sessions twice weekly. Three of three client records, # 7, 8 and 10, failed to include documentation of two individual treatment sessions per week at this partial hospitalization level of care.
|
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.
|
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 weekly case consultation notes as required by facility policy in three of three client records.
The findings included:
Three client records were reviewed during the onsite licensing inspection of January 12-13, 2009. Each client record was required to have documentation of weekly multidisciplinary staff meetings. Weekly meetings were not documented in client records # 7, 8 and 10.
|
Plan of Correction
It is the policy of this agency that Case Consultations occur in a weekly multi-disciplinary staff meeting at least once per quarter. The Project and Facility Director shall rewrite the Policy and Procedure for Case Consultations to more clearly reflect this process. It shall be the responsibility of the Clinical Supervisor to insure case consultations are completed at least once per quarter in the weekly multi-disciplinary staff meeting and documented to accurately reflect this activity. |
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 personnel records and client records, the facility failed to ensure that an informed and voluntary consent was documented for each release of information.
The findings included:
Four employee records were reviewed at this facility during the onsite licensing inspection of January 12-13, 2009. Full names of clients were documented in employee records # 2 and 3. The client names appeared on billing forms which were kept in the employee records. Seven client records were reviewed during the onsite licensing inspection of January 12-13, 2009. Client record # 10 included documentation that a client's significant other was in a therapy session with the client, but there was no consent to release information form that permitted the facility to allow the significant other access to confidential information.
|
Plan of Correction
It shall be the responsibility of the Clinical Supervisors to review and reinforce the Laws Governing Drug and Alcohol Confidentiality with treatment staff, specifically but not limited to, the requirement to have a valid, signed, informed consent to outside parties in order to release pertinent information within the confines of the law. In addition that at no time should a clients' full name be placed on a time sheet at any time. It shall be the responsibility of the Clinical Supervisors to insure ongoing compliance with this regulation through weekly chart 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.
|
Observations
Based on the review of the client records, the facility failed to document complete personal histories in seven of nine client records.
The findings include:
Seven client records were reviewed during the onsite licensing inspection of January 12-13, 2009. Each client record was required to have a personal history documented as part of the intake process. Family relationships were not documented in client records #1, 2, 5, 6, 9, and 11. Employment histories in client records # 1, 2, 4 and 9 were incomplete, addressing only current employment, but not providing the work history.
|
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 employment 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)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
|
Observations
Based on the review of client records, the facility failed to document consent to treatment forms in two of seven client records.
The findings included:
The record sample consisted of seven client records reviewed on January 12-13, 2009. There was no documentation of consent to treatment forms in client records # 5 and 9.
|
Plan of Correction
It is the policy of this agency that all clients must sign a Consent to Treatment in order to be admitted into the facility. It shall be the responsibility of the Clinical Supervisor to review this policy with the clinical staff and 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.
|
Observations
Based on the review of client records, the facility failed to document complete psychosocial evaluations in six of seven client records.
The findings included:
Seven client records were reviewed on January 12-13 , 2009. Each client records was required to have a complete psychosocial evaluation.
There was no documentation of a psychosocial evaluation in client record # 11.
The psychosocial evaluations in client records # 1, 2, 5, 6 and 9 did not identify client needs and underlying problems.
The psychosocial evaluations in client records #1, 2, 5 and 9 did not include documentation of coping and defense mechanisms.
The psychosocial evaluation in client record # 6 did not include documentation of negative factors which might impact on the client's recovery efforts during the treatment episode.
Clinical impressions in client records #1, 2, 5, 6, 9 and 11 did not document interpretations of the collected historical information , how it led to the client's current situation or implications for treatment.
|
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)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment on each treatment plan in five of seven client records..
The findings included:
Seven client records were reviewed during the onsite licensing inspection of January 12-13, 2009 . Each client record was required to have documentation of the type and frequency of services to be provided to the client. Client records # 1, 2, 5, 6 and 9 did not provide documentation of the type and frequency of services.
|
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 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. |
709.92(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 treatment plan updates in three of six client records.
The findings included:
Seven client records were included in the sample reviewed. Six client records were required to have treatment plan updates. There was no documentation of treatment plan updates in client records # 6, 9 and 11.
|
Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review the requirement to update treatment plans at least every 60 days 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)(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 during the onsite licensing inspection of January 12-13, 2009, the facility failed to document a case consultation on each client.
The findings included:
Seven client records were reviewed during the onsite licensing inspection . Three client records were required to have documented case consultations. Client record # 6 did not include documentation of a case consultation as required.
|
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)(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.
|
Observations
Based on a review of client records, the facility failed to document a complete discharge summary on each client.
The findings included:
Seven client records were reviewed during the onsite licensing inspection of January 12-13, 2009. Three client records in this sample were required to have documentation of complete discharge summaries.
Client record #4 did not include documentation on the discharge summary of the reasons the client sought treatment, the services offered to the client, or the client's response to treatment.
Client record # 5 did not include documentation on the discharge summary of the status of the client at discharge, nor the client's response to treatment.
|
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, status at discharge, and client's response to 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. |