INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 18 - 19, 2011 and January 31, 2011 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 3, 2011.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of staffing requirements facility summary reports and an interview with the facility director, the project failed to provide a full-time clinical supervisor for every eight full-time counselors and counselor assistants.
The findings include:
Six staffing requirements facility summary reports were reviewed on January 18 - 21, 2011. The project consists of six facilities. These six facilities are managed by one facility director. Per regulation, a drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both. As of January 21, 2011, the project has 29.35 full-time counselors and only two full-time clinical supervisors. Three full-time clinical supervisors would be required for 29.35 full-time counselors.
The facility director was interviewed throughout the inspection process from January 18 - 21, 2011. The facility director confirmed that there are only two full-time clinical supervisors for the project.
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Plan of Correction
Project Director and Facility Director will transfer 1 Supervisor to Full-Time Drug and Alcohol Clinical Supervisor position to provide 3 Full-Time Drug and Alcohol Clinical Supervisors for the project to meet this regulation.
It shall be the responsibility of the Project Director and Facility Director to insure there is 1 Full-Time Drug and Alcohol Clinical Supervisor for every 8 Full-Time Equivalent Counselors and Counselor Assistants for this project. It shall also be the responsibility of the Project Director and Facility Director to insure these Full-Time Drug and Alcohol Supervisors have no other duties assigned and ongoing compliance with these regulations through quarterly staffing pattern reviews.
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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 a review of client records, qualified service organization agreements and an interview with the facility director and clinical supervisor, the facility failed to document an informed and voluntary consent or a qualified service organization agreement when releasing urine samples to an outside agency for testing in four out of ten client records.
The findings include:
Fourteen client records were reviewed on January 31, 2011. Urine samples were sent to an outside agency in ten client records. Four client records included urine tests that were from a time frame outside of the current licensing inspection. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. Client records # 2, 6, 7 and 8 did not include a signed release of information nor was a qualified service organization agreement in place for the outside agency.
Client # 2 was admitted into treatment on December 27, 2010. Urine samples were released to an outside agency without a consent to release information or a qualified service organization agreement on the following dates: December 17 and December 27, 2010.
Client # 6 was admitted into treatment on July 7, 2010. Urine samples were released to an outside agency without a consent to release information or a qualified service organization agreement on the following dates: January 12, 2011.
Client # 7 was admitted into treatment on September 1, 2010. Urine samples were released to an outside agency without a consent to release information or a qualified service organization agreement on the following dates: September 8, September 30, October 13, October 25 and November 18, 2010 and January 19, 2011.
Client # 8 was admitted into treatment on August 25, 2010. Urine samples were released to an outside agency without a consent to release information or a qualified service organization agreement on the following dates: September 8, November 18 and December 23, 2010.
The facility director was interviewed on January 31, 2011 and confirmed the facility had been unable to obtain a qualified service organization agreement with one of the agencies that conducts urine testing. The facility director also confirmed that informed and voluntary consents had not been completed for clients # 2, 6, 7 and 8. The facility director reported that staff have been instructed to obtain a consent to release information when utilizing this outside agency.
This is a repeat citation.
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Plan of Correction
Clinical staff will obtain a Release of Information for Clients # 2,6, 7, and 8, for the outside agency that conducts laboratory/urine work for this agency.
It shall be the responsibility of the Clinical Supervisor to review and train staff on the requirement to obtain a release of information for this laboratory facility. It shall also be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart 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 a review of client records and and staff interviews, the facility failed to document treatment plan review and updates within sixty days, in five of six outpatient client records.
The findings include:
Fourteen client records were reviewed on January 31, 2011. Nine client records pertained to the outpatient activity. Six client records required treatment plan review and updates. Per the facility policy, treatment plan review and updates are required to be completed every sixty days. The facility failed to document treatment plan review and updates within sixty days, in client records # 6, 7, 8, 12 and 13.
In client record # 6, the client was admitted into treatment on July 7, 2010. The individual treatment plan was completed on July 15, 2010. The first treatment plan update was completed on September 15, 2010. The second treatment plan update was due to be completed no later than November 15, 2010. The third treatment plan update was due to be completed no later than January 15, 2011. Verification of the second and third treatment plan updates was not documented at the time of the review on January 31, 2011.
In client record # 7, the client was admitted into treatment on September 1, 2010. The individual treatment plan was completed on September 22, 2010. Treatment plan updates were due to be completed no later than November 22, 2010 and January 22, 2011. Verification of the treatment plan updates was not documented at the time of the review on January 31, 2011.
In client record # 8, the client was admitted into treatment on August 25, 2010. The individual treatment plan was completed on September 2, 2010. The first treatment plan update was due to be completed no later than November 2, 2010 but was not completed until November 24, 2010. The second treatment plan update was due to be completed no later than January 24, 2011. Verification of the second treatment plan update was not documented at the time of the review on January 31, 2011.
In client record # 12, the client was admitted into treatment on February 2, 2010. The individual treatment plan was completed on March 5, 2010. Treatment plan updates were due to be completed no later than May 5, July 5, September 5, November 5, 2010 and January 5, 2011. Verification of the treatment plan updates was not documented at the time of the review on January 31, 2011.
In client record # 13, the client was admitted into treatment on September 22, 2010. There was no documentation of an individual treatment plan; which was due to be completed no later than October 22, 2010. A treatment plan update was due to be completed no later than December 22, 2010. Verification of the treatment plan update was not documented at the time of the review on January 31, 2011.
The facility director and clinical supervisor were interviewed on January 31, 2011 and confirmed the treatment plan updates were not completed within the 60 day timeframe.
This is a repeat citation.
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Plan of Correction
Clinical Staff will immediately review and update treatment plans with Clients # 6,7,8,12, and 13.
A new Clinical Supervisor for this facility was hired on December 20, 2010 and will review and train staff regarding the requirement to review and update the treatment plan every 60 days with clients.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart 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 and staff interviews, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in three of five outpatient client records.
The findings include:
Fourteen client records were reviewed on January 31, 2011. Five treatment plans and updates were reviewed to assure that counseling services were provided according to the treatment plan. The facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in client records # 6, 7 and 8.
Client # 6 was admitted into treatment on July 7, 2010. The individual treatment plan was completed on July 15, 2010. The treatment plan indicated individual counseling would be completed one time per week. A treatment plan update was completed on September 15, 2010 and also indicated once a week individual counseling sessions. No other treatment plan updates were documented. Individual sessions were provided on the following dates: July 15, August 19, September 15, September 22, October 6, November 18, November 24, December 2 and December 19, 2010. Individual sessions were not conducted again until January 13 and January 19, 2011. There was no documentation that counseling sessions had been cancelled or missed by the client.
Client # 7 was admitted into treatment on September 1, 2010. The individual treatment plan was completed on September 22, 2010. The treatment plan indicated individual counseling would be provided one time weekly. There were no updates to this treatment plan. The only documented individual sessions were on September 22, September 29 and November 11, 2010. There was no documentation that counseling sessions had been cancelled or missed by the client.
Client # 8 was admitted into treatment on August 25, 2010. The individual treatment plan was completed on September 2, 2010. The treatment plan indicated individual counseling would be completed one time per week. A treatment plan update was completed on November 24, 2010 and also indicated once a week individual counseling sessions. No other treatment plan updates were documented. Individual sessions were provided on the following dates: September 2, September 8, November 1, November 24 and December 29, 2010. There was also one individual session on January 13, 2011. There was no documentation that counseling sessions had been cancelled or missed by the client.
The facility director and clinical supervisor were interviewed on January 31, 2011 and confirmed that client records # 6, 7 and 8 did not document individual sessions according to the treatment plans. They also confirmed these records did indicate whether the clients had missed or cancelled sessions.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train staff on providing and documenting counseling sessions as indicated by the treatment plan and results of all scheduled appointments accurately, including all cancelled, no-showed, or rescheduled appointments.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with appropriate treatment planning and counseling session documentation through weekly clinical and chart supervision. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records and staff interviews, the facility failed to document that counseling was provided to a client on a regular and scheduled basis in three of six outpatient client records.
The findings include:
Fourteen client records were reviewed on January 31, 2011. Nine client records pertained to the outpatient activity. Six client records were reviewed to determine if counseling was provided to clients on a regular and scheduled basis. The facility failed to provide documentation of regular and scheduled counseling sessions in client records # 6, 7 and 8.
Client # 6 was admitted into treatment on July 7, 2010. Client # 6 was participating in the Intensive Outpatient Program. Per the clinical supervisor, clients in this level of activity participate in one individual counseling session per week. This is documented on the individual treatment plan dated July 15, 2010. Progress notes and the record of services provided were reviewed for documentation of regular and scheduled individual counseling sessions. The progress notes have a section on the bottom to enter the client's next appointment time and date. "To be determined" was the only entry made in all of the individual progress notes reviewed. The record of services provided did not include any documentation of regular and scheduled individual counseling sessions with the client.
Client # 7 was admitted into treatment on September 1, 2010. Client # 7 was participating in the Intensive Outpatient Program. Per the clinical supervisor, clients in this level of activity participate in one individual counseling session per week. This is documented on the individual treatment plan dated September 22, 2010. Progress notes and the record of services provided were reviewed for documentation of regular and scheduled individual counseling sessions. The progress notes have a section on the bottom to enter the client's next appointment time and date. "To be determined" was the only entry made in all of the individual progress notes reviewed. The record of services provided did not include any documentation of regular and scheduled individual counseling sessions with the client.
Client # 8 was admitted into treatment on August 25, 2010. Client # 8 was participating in the Intensive Outpatient Program. Per the clinical supervisor, clients in this level of activity participate in one individual counseling session per week. This is documented on the individual treatment plan dated September 2, 2010. Progress notes and the record of services provided were reviewed for documentation of regular and scheduled individual counseling sessions. The progress notes have a section on the bottom to enter the client's next appointment time and date. Only two individual counseling sessions were scheduled for August 25, 2010 and November 11, 2010. "To be determined" was the entry made in all of the other individual progress notes reviewed. The record of services provided did not include any documentation of regular and scheduled individual counseling sessions with the client.
The facility director and clinical supervisor were interviewed on January 31, 2011. The facility director confirmed that the project policy is for the counselors to schedule regular counseling sessions with the client and document this on the progress notes. The facility director reported the facility had some difficulty with clinical staff turnover this past year.
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Plan of Correction
Client records 6,7, and 8 will be corrected to document regular counseling sessions were scheduled, and whether clients cancelled or no-showed these appointments.
The Clinical Supervisor will review and train staff on appropriate documentation and scheduling of regular counseling sessions on progress notes, records of service, and treatment plans.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart 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 the facility's policy and procedure, client records and staff interviews, the facility failed to document a case consultation in three of six outpatient client records.
The findings include:
Fourteen client records were reviewed on January 31, 2011. Nine client records pertained to the outpatient activity. Case consultations were required in six client records. Per regulation, there shall be a complete client record on an individual which includes information relative to the client's involvement with the project and this shall include case consultation notes. The agency policy requires a case consultation to be completed every 90 days. The facility did not document case consultations in client records # 7, 8 and 12.
Client # 7 was admitted into treatment on September 1, 2010. A case consultation was due to be completed no later than December 1, 2010. The facility failed to document the completion of any case consultations.
Client # 8 was admitted into treatment on August 25, 2010. A case consultation was due to be completed no later than November 25, 2010. The facility failed to document the completion of any case consultations.
Client # 12 was admitted into treatment on February 2, 2010. Case consultations were due to be completed no later than May 2, August 2 and November 2, 2010. The facility failed to document the completion of any case consultations.
The facility director and clinical supervisor were interviewed on January 31, 2011 and confirmed these client records did not contain the required case consultations. The facility director reported that the facility has experienced a turnover in clinical supervisors and counselors.
This is a repeat citation.
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Plan of Correction
Clinical staff will immediately complete case consultation on clients #7,8, and 12.
The Clinical Supervisor shall review and train all clinical staff on the requirement and appropriate documentation of case consultations every 90 days.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records and staff interviews, the facility failed to document follow-up information in three of three outpatient client records.
The findings include:
Fourteen client records were reviewed on January 31, 2011. Nine client records pertained to the outpatient activity. Four client records were closed and three client records required the completion of a follow-up. Follow-ups were not yet due in one of the closed client records. Per the agency policy, follow-up is required within six months of discharge. The facility did not document follow-up information in client records # 10, 11 and 12.
Client # 10 was admitted into treatment on May 13, 2010 and discharged on July 24, 2010. Follow-up was due to be completed no later than January 24, 2011. Follow-up verification was not documented at the time of the review on January 31, 2011.
Client # 11 was admitted into treatment on April 6, 2010 and discharged on June 28, 2010. Follow-up was due to be completed no later than December 28, 2010. Follow-up verification was not documented at the time of the review on January 31, 2011.
Client # 12 was admitted into treatment on February 2, 2010 and discharged on July 27, 2010. Follow-up was due to be completed no later than January 27, 2011. Follow-up verification was not documented at the time of the review on January 31, 2011.
The facility director and clinical supervisor were interviewed on January 31, 2011 and confirmed that follow-up documentation was not available for client records # 10, 11 and 12.
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Plan of Correction
Follow-Up letters will be sent out immediately to clients # 10,11, and 12.
It shall be the responsibility of the Clinical Supervisor to review and train clerical staff on the requirement of sending out Follow-Up letters to discharged clients 6 months after discharge.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through quarterly reviews of discharged charts. |