INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 25 - 26, 2010 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 22, 2010.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, CPR/first aid certification cards and an interview with the facility director, the facility failed to ensure that van drivers who transport clients had documentation of CPR/first aid training in two of three personnel records.
The findings include:
Fourteen personnel records and employee CPR/first aid certification cards were reviewed on February 23 - 24, 2010. Three employees are van drivers. Two van drivers did not have documentation of CPR/first aid training. Employees # 13 and 14 did not have documentation of CPR/first aid training.
Employee # 13 was hired on November 3, 2008. Employee # 13 is a van driver and transports clients. Employee record # 13 did not have documentation of CPR/first aid training.
Employee # 14 was hired on October 7, 2008. Employee # 14 is a van driver and transports clients. Employee record # 14 did not have documentation of CPR/first aid training.
The facility director was interviewed on February 24 and 26, 2010. The facility director reported she was unable to obtain documentation of CPR/first aid certification for employees # 13 and 14. The facility director reported these are contract employees and they are required to have CPR/first aid certification.
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Plan of Correction
Employees #13 and #14 will be trained in First Aid and CPR.
It shall be the responsibility of the Clinical Supervisors to insure compliance with this regulation through scheduling and monitoring attendance for all employees who need CPR/First Aid training and insuring copies of certifications are kept on file.
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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.
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Observations
Based on a review of the staffing requirements facility summary report form completed by the facility on February 25, 2010 and an interview with the facility director, the facility failed to ensure that counselor outpatient caseloads were at or below 35 active clients per one Full Time Equivalent (FTE) counselor.
The findings included:
On February 25, 2010, ten counselor outpatient caseloads were reviewed on the facility summary report form. Per regulation, the caseload for counseling in outpatient programs may not exceed 35 clients per one FTE counselor. Based on the number of hours the employees worked at this facility, and the number of clients on the counselors' caseload, three counselors exceeded the maximum outpatient caseload of 35:1. One counselor had a caseload of 40:1 and two counselors had a caseload of 38:1.
The facility director was interviewed on February 25, 2010 at approximately 11:00 AM. The facility director confirmed these counselors were over the required caseload of 35:1. The facility director will discuss this with the clinical supervisors; who assign clients to the counselors to ensure that counselor caseloads remain at or below 35:1.
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Plan of Correction
Facility Director has increased the three identified counselors' work hours to meet the 35:1 caseload ratio.
It shall be the responsibility of the Clinical Supervisor to insure that all counselor caseloads do not exceed the 35:1 outpatient caseload ratio through weekly monitoring of caseload rosters and admissions and discharges.
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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, 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 twenty-one of twenty-four client records.
The findings include:
Twenty-four client records were reviewed on February 25 - 26, 2010. Urine samples were sent to an outside agency in twenty-one client records. Three clients were not participating in urine testing. Client records # 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 22, 23 and 24 did not include a signed release of information nor was a qualified service organization agreement in place for the outside agency.
The facility director was interviewed on February 25, 2010 at approximately 2:30 PM and confirmed the facility did not have a qualified service organization agreement with the agency that conducts urine testing. The facility director also confirmed that informed and voluntary consents had not been completed for clients who were participating in urine testing. The facility director reported a qualified service organization agreement will be obtained with the agencies that provide this testing for the facility.
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Plan of Correction
Project Director will obtain a Qualified Service Organization Agreement with all testing companies for the purpose of releasing drug testing samples and bloodwork. Clinical Supervisor will train all staff to obtain a Consent to Release the drug test to appropriate testing facility until such time the QSOA is signed and received by Facility.
It shall be the responsibility of the Project and Facility Directors to obtain and maintain all QSOAs with testing companies for drug testing and bloodwork. It shall be the responsibility of the Project and Facility Director to insure ongoing compliance with this regulation through yearly reviews of all QSOAs.
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