INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 8-11, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on June 12, 2007.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Staff did not utilize the mechanism to provide feedback for the training attended according to program policy. Inconsistent documentation was noted in employee files # 1, 2, 3, 7 and 8.
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Plan of Correction
Communication and paperwork submission is an identified issue between SPHS Behavioral Health and SPHS Inc Human Resource Department. Project Director will submit a reminder memo to all staff regarding the requirement to use the Staff Development and Feedback Form when attending any training and submit to their respective supervisor for submission to Human Resources. Human Resource Director and Project Director will ensure ongoing compliance with this regulation through ongoing monitoring of Personnel Records. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The required mandatory communicable disease training hours were not documented in employee files # 1, 3, 6, 9 and 10.
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Plan of Correction
Employee #1 certificate was missing and will be retrained.
Employee #3 was hired December 2006 and has 6 months to comply with this regulation.
Employee #6 is Medical Director and agrees to either attend a CME approved training on HIV/AIDS or teach a 6 hour HIV/AIDS course.
Employee #10 certificate was missing and will be retrained.
*** Employee #9 is employed as a DUI Intervention Specialist and has no access to D&A treatment records and has no involvement in identifying individuals involved in D&A treatment or making referrals to D&A treatment.
It shall be the responsibility of the Human Resource Director and Project Director to ensure ongoing compliance with this regulation through ongoing monitoring of Personnel Records. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Instruction in the use of fire extinguishers was not documented for all staff. Documentation was missed in employee files # 4, 5, 6, 8, 9 and 10.
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Plan of Correction
SPHS Behavioral Health has provided training to all drug and alcohol treatment staff regarding the use of fire extinguishers, however due to lack of documentation in Personnel Records, employees listed will be retrained and documentation placed in respective Personnel Records.
It shall be the responsibility of the Facility Director and Clinical Supervisor to ensure all staff continue to be trained on Fire Extinguishers within 7 days of hire and document such training. It shall be the responsibility of the Human Resource Director that documentation is placed in the Personnel Record and ensure ongoing compliance through monitoring of Personnel Records. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Instruction in emergency procedures was not documented for all staff. Documentation was missing in employee files # 4, 5, 6, 8, 9 and 10.
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Plan of Correction
SPHS Behavioral Health has provided training to all drug and alcohol treatment staff regarding Emergency Procedures, however due to lack of documentation in Personnel Records, employees listed will be retrained and documentation placed in respective Personnel Records.
It shall be the responsibility of the Facility Director and Clinical Supervisor to insure all staff continue to be trained in Emergency Procedures within 7 days of hire and document such training. It shall be the responsibility of the Human Resource Director that documentation is placed in the Personnel Record and insure ongoing compliance through monitoring of Personnel Records. |
705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Protective caps were not kept on outlets in the children's therapy area.
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Plan of Correction
Protective caps over outlets were an oversight on behalf of SPHS Behavioral Health.
Facility Director will place protective caps over all outlets in the children's therapy area and will insure caps remain in place through monthly monitoring of children's therapy area. |
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
Personal histories were incomplete in client records # 7, 20 and 21.
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Plan of Correction
Personal histories are completed in reference to the information provided by the client. Staff make all efforts to obtain as much information as possible, however may be limited due to client's unwillingness to provide information at the time of interview.
It shall be the responsibility of the Facility Director and Clinical Supervisor to review required components of the personal history. In addition, Facility Director and Clinical Supervisor will discuss efforts to obtain as much information as possible and document in the personal history with clinical staff. |
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
Psychosocial evaluations did not contain complete information. Client record # 16 did not address client needs, composite picture or negative factors impacting treatment in detail.
Client record # 20 and 21 did not address negative factors or composite picture.
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Plan of Correction
SPHS Behavioral Health makes every effort to assist staff in developing the skills necessary to write sufficient psychosocial evaluations. Writing skills of various staff differ and are regularly reviewed and discussed through clinical supervision and chart reviews.
It shall be the responsibility of the Facility Director and Clinical Supervisor to review and provide examples indicated during the recent Department of Health Licensing visit as meeting this standard. Facility Director, Clinical Supervisor, and Lead Therapist will insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews. |
709.83(a)(9) 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:
(9) Progress notes.
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Observations
Group notes did not address group interaction or dynamics in the files reviewed. When group sessions are conducted, individual notes need not be written for each client. One group note will suffice provided that it includes a comment relative to each individual's response or participation in the group session.
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Plan of Correction
SPHS Behavioral Health chooses to use individual notes for each participant in group sessions. Group interaction or dynamics for each member need to be better documented.
It shall be the responsibility of the Facility Director and Clinical Supervisor to review and train staff on group note documention, including the group member's interaction or group dynamics. It shall be the responisibility of the Facility Director, Clinical Supervisor, and Lead Therapist to insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
The manual at the main administrative office was not consistent with regard to policies and procedures. The general organization of the manual made the review difficult and increased the potential for misunderstanding the intent of various procedures. The manual should include consistent policies and procedures and should be organized to permit staff to readily access needed information.
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Plan of Correction
SPHS Behavioral Health will correct all deficiencies and reorganize the manuals to meet current manual standards.
It shall be the responsibility of the Project and Facility Director to insure the Policy and Procedures Manuals remain in compliance with standards through annual review of the manuals.
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709.24(a)(2) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(2) Treatment models utilized by the project.
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Observations
The manual identified a number of different treatment models but did not define each one, choosing only to define the existential model and the criminal personality model. In order to determine that the project is providing client services consistent with the treatment models used, definitions of the specific agency application of each treatment model must be included.
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Plan of Correction
The missing definitions are an oversight on the part of the Facility Director.
Project and Facility Director will include definition to the verious treatment models used by SPHS Behavioral Health. It shall be the responsibility of the Facility Director and Clinical Supervisor to insure clinical documentation is consistent with the models as they are defined through clinical supervision and weekly chart reviews. |
709.26(d)(3) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(3) The verification of training experience and professional licensure or registration, where applicable.
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Observations
Training and experience was not consistently documented in employee files reviewed. Employee files # 4, 5 and 8 did not have documentation of fire extinguisher and emergency procedure training. Employee file # 6 did not have a copy of the current license on file. Employee file # 4 did not have one of the approved degrees specified in the Licensing Alert of October 2002, and no documentation was on file to demonstrate that the degree had been reviewed and approved by the Division. When staff hired have degrees not specified as appropriate in the Licensing Alert the degree and transcript should be forwarded to the Division for review and approval.
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Plan of Correction
SPHS Behavioral Health and SPHS Inc Human Resource Department are working collaboratively to address the issue of documentation of training in Personnel Records.
It shall be the responsibility of the Facility Director and Clinical Supervisor to insure all staff are trained in Fire Extinguishers and Emergency Procedures within 7 days of hire and document such training. It shall be the responsibility of the Project Director to insure a copy of current medical license is on file for physicians. Facility Director will obtain approval from the Department of Health when hiring any individual who does not have an approved degree. It shall be the responsibility of the Human Resource Director to insure all documentation is placed in respective person's Personnel Record and insure ongoing compliance through monitoring of Personnel Records. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
The client record room is not used exclusively for the storage of client records. Records must be stored in accordance with the Licensing Alert of November, 2004.
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Plan of Correction
SPHS Behavioral Health felt that due to limited access to the medical records area, this area was sufficient to meet this regulation.
Facility Director will move Mailboxes and Literature Rack to another area of the program. This will insure only client records will be placed in the client record room and will not be used for any other purpose.
It shall be the responsibility of the Facility Director will insure the client record room is used for the sole purpose of record storage on an ongoing basis. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
The purpose was unclear on release forms in each of the records reviewed. The purpose must identify the reason for the release of information to the person or entity specified.
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Plan of Correction
SPHS Behavioral Health did not provide a logically consistent purpose of the release of information in regards to the function of the entity receiving information.
It shall be the responsibility of the Facility Director and Clinical Supervisor to review and train staff on clearly identifying the purpose of the informed consent and specify a logical and consistent reason for the release in regards to the function of a specific person or entity to insure only required and pertinent information is released. It shall be the responsibility of the Facility Director and Clinical Supervisor to insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews. |
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
Personal histories did not adequately address the areas required in sufficient detail in 11 of 16 client records reviewed, (2, 4, 6, 8, 9, 10, 11, 14, 17, 18, 19) Personal histories should collect as much personal information about a client as possible since they form the basis from which the psychosocial evaluation and subsequent treatment plans are formulated.
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Plan of Correction
SPHS Behavioral Health makes every attempt to obtain as much information regarding personal histories on each client as possible. However we are limited to the information the client is willing to provide to the counselor.
It shall be the responsibility of the Facility Director and Clinical Supervisor to review required components of the personal history. In addition, Facility Director and Clinical Supervisor will discuss efforts to obtain as much information as possible and document information in the personal history with clinical staff. It shall be the responsibility of the Facility Director and Clinical Supervisor to insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews. |
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
Psychosocial evaluations in 12 of 16 client records were lacking complete information. (Client records # 1, 2, 5, 9, 10, 11, 12, 13, 14, 15, 17 and 18).
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Plan of Correction
It shall be the responsibility of the Facility Director and Clinical Supervisor to review all the required elements of the psychosocial evaluation as defined in regulation, including but not limited to the negative factors and to provide as much detail as possible in order to provide a composite picture. Examples will be provided indicated during the recent Department of Health Licensing visit as meeting this standard, to clinical staff. Facility Director, Clinical Supervisor, and Lead Therapist will insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
The treatment goals listed in the treatment plans of 6 of 16 client records reviewed did not contain, or were unclear, in identifying measurable criteria to determine achievement of progress. (Client records # 1, 2, 3, 11, 13 and 19).
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Plan of Correction
SPHS Behavioral Health makes every effort to develop treatment plans which are clear and include measurable criteria.
It shall be the responsibility of the Facility Director and Clinical Supervisor to review and provide examples, indicated during the recent Department of Health Licensing visit as meeting this standard, to clinical staff. Facility Director, Clinical Supervisor, and Lead Therapist will insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Group notes in each of the client records reviewed failed to include any information about group interactions and dynamics. When group sessions are conducted, individual notes need not be written for each client. One group note will suffice provided that it includes a comment relative to each individual's response or participation in the group session.
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Plan of Correction
SPHS Behavioral Health chooses to use individual notes for each participant in group sessions. Group interaction or dynamics for each member need to be better documented.
It shall be the responsibility of the Facility Director and Clinical Supervisor to review and train staff on group note documentation, including the group member's interaction or group dynamics. It shall be the responsibility of the Facility Director and Clinical Supervisor to insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews. |
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
Follow up was not documented in accordance with agency policy in one of two applicable client records (#9).
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Plan of Correction
The Follow-Up Policy in the manual was inconsistent with the practice of the programs.
Project and Facility Director will rewrite the Follow-Up Policy to accurately reflect that Follow-Up is conducted at 6 months post-treatment. It shall be the responsibility of the Facility Director and Clinical Supervisor to insure ongoing compliance with the Follow-Up policy as it is stated within the Follow-Up policy through random supervision of discharged charts. |