INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 2, 2017 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.
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Plan of Correction
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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
The facility failed to document at least 25 hours of annual training required for counselors in one of two personnel records reviewed during the annual licensing inspection conducted on February 2, 2017.
Counselor # 4 was hired February 16, 2014. Only 18 hours of training were documented for the July 1, 2015 - June 30, 2016 training year.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will review with
supervisor the policy and procedure
of ensuring that all staff require the
mandatory trainings to meet state
regulations including the requirement of at least 25 ours of annual training four counselors. Employee number 4 will
be reminded of the training regulation of receiving 25 hours of annual training. The Clinical supervisor will
ensure that this staff and any future
staff attend mandatory trainings hours in the appropriate time frames. This will be completed by 2/28/17. |
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.
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Observations
The facility failed to document an informed and voluntary consent from the client that was compliant with 4 Pa. Code 255.5 (b) in three of nine client records reviewed during the annual licensing inspection conducted on February 2, 2017.
The following client records were not compliant with 4 Pa. Code 255.5 (b), as the consents to the probation office indicated urine results, results of assessment and treatment goals would be released.
Client # 1 was admitted into treatment on November 2, 2016. The consent was signed by the client on November 2, 2016.
Client # 2 was admitted into treatment on November 9, 2016. The consent was signed by the client on November 9, 2016.
Client # 5 was admitted into treatment on April 6, 2016 and discharged on June 7, 2016. The consent was signed by the client on April 6, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will obtain appropriate Consents to Release Information for client numbers 1, 2, and 5 where obtaining the consents are possible and remain relevant. The Clinical Supervisors will develop and provide a training update of the accurate and appropriate completion of consents to release information by Feb 28th 2017. Information to be covered will include appropriate type of release, the appropriate release for funding source and probation appropriate choice of information to be released; and limitations of 4 Pa. code subsection 255.5, at a minimum. This will be completed by Feb 28th 2017. Clinical Supervisor will continue to review and monitor consents and releases through internal chart reviews and 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.
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Observations
The facility failed to document treatment plan updates at least every 60 days in three of nine client records reviewed during the annual licensing inspection conducted on February 2, 2017.
Client # 1 was admitted into treatment on November 2, 2016. The treatment plan was completed November 2, 2016 and a treatment plan update was not documented until January 13, 2017.
Client # 8 was admitted into treatment on August 15, 2016 and discharged on January 11, 2017. The treatment plan was completed August 15, 2016 and a treatment plan update was not documented until January 4, 2017.
Client # 9 was admitted into treatment on September 23, 2016 and discharged on January 27, 2017. The treatment plan was completed September 23, 2016 and no treatment plan updates were documented.
The findings were reviewed with staff during the licensing process.
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Plan of Correction
A mandatory staff meeting will be held with all staff to review plan of care timelines and regulations. This will occur no later than Feb 28th 2017. Each staff member will be provided with a copy of our agency's policy and regulations in regard plan of care timelines. In addition supervisor will review discharge time frames to reduce the likelihood of late plan of cares.To assure staff members are improving in this area internal chart reviews and supervision will take place 2/28/17 by the Clinical Supervisor. |