INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 3 4, 2013 by staff from the Program Licensure Division. 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.
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Plan of Correction
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director.
The findings include:
Twelve personnel records were reviewed on December 4, 2013. One personnel record pertained to the project director and required documentation of 12 clock hours of annual training. The training year reviewed was from July 1, 2012 through June 30, 2013. The facility failed to document 12 clock hours of annual training for the 2012/2013 training year in personnel record # 1.
Employee # 1 was hired as the project director on July 1, 1978. Employee # 1 only had 10 clock hours of annual training documented for the 2012/2013 training year.
The facility director confirmed the findings.
This is a repeat citation from the February 14 - 15, 2013 licensing inspection.
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Plan of Correction
The Project Director has completed 6.5 hours of training this training year. The Project Director will complete another 5.5 hours of training to meet the 12 hours of training required per this regulation.
It shall be the responsibility of the Project Director to insure 12 hours of training are obtained each training year.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one personnel records.
The findings include:
Twelve personnel records were reviewed on December 4, 2013. Eight personnel records pertained to counselors. One counselor required the completion of 25 clock hours of annual training. Seven counselors were new hires and not yet due to complete annual training hours. The training year reviewed was from July 1, 2012 through June 30, 2013. The facility failed to document 25 clock hours of annual training for the 2012/2013 training year in personnel record # 12.
Employee # 12 is a counselor and was hired on April 5, 2006. Personnel record # 12 only included documentation of 3 clock hours of annual training for the 2012/2013 training year.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the February 14 - 15, 2013 licensing inspection.
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Plan of Correction
Clinical Supervisors shall be responsible for insuring clinical staff obtain 25 hours of training in the training year. Facility Director shall review training documentation with Clinical Supervisor to insure all training opportunities, internally and externally, are documented to meet this regulation.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through quarterly reviews of employee trainings
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705.24 (1) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(1) Provide bathrooms to accommodate staff, clients and other users of the facility.
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Observations
Based on a physical plant inspection conducted on December 4, 2013, the facility failed to ventilate the men's bathroom in the basement by exhaust fan or window.
The findings include:
A physical plant inspection was conducted with the clinical supervisor on December 4, 2013 at approximately 9:00 AM. The men's bathroom located in the basement (lower level) did not have a window or an operable exhaust fan.
The clinical supervisor confirmed the findings.
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Plan of Correction
Project and Facility Director will review this regulation with facility landlord to have bathroom fan replaced in men's bathroom in the basement.
It shall be the responsibility of the Clinical Supervisor to insure all bathrooms are ventilated by exhaust fan or window at all times.
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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection conducted on December 4, 2013, the facility failed to maintain a well secured handrail on the outside steps leading to the subbasement emergency exit.
The findings include:
A physical plant inspection was conducted with the clinical supervisor on December 4, 2013. The subbasement was inspected at approximately 9:10 AM. There is an emergency exit from the subbasement leading to the outside of the building and three outside steps. The metal handrail for these outside steps was loose and one post was no longer attached to the concrete steps. The facility failed to maintain a well-secured handrail on the outside steps.
The clinical supervisor confirmed the findings.
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Plan of Correction
Project and Facility Director will review this regulation with facility landlord to have handrail replaced on outside steps leading to the sub-basement emergency exit.
It shall be the responsibility of the Clinical Supervisor to insure all exits are safe and operable at all times. |