INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 7, 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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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 obtain an informed and voluntary consent from the client prior to the disclosure of information in one of nine client records reviewed during the annual licensing inspection conducted on February 7, 2017. In addition, the project exceeded the limitations imposed at 4 Pa. Code 255.5 (b) in three of nine client records.
A consent to release information was not documented for a treatment provider and the facility disclosed by fax the client's name, evaluation results and progress reports in the following client record.
Client # 1 was admitted into treatment on August 31, 2016. The disclosures occurred on September 6, November 21 and December 7, 2016.
The following client records were not compliant with 4 Pa. Code 255.5 (b), as the consents to the funding entity indicated urine results, results of assessment and treatment goals would be released.
Client # 3 was admitted into treatment on October 3, 2016. The consent was signed by the client on October 3, 2016.
Client # 8 was admitted into treatment on September 28, 2016 and February 6, 2017. The consent was signed by the client on September 28, 2016.
Client # 9 was admitted into treatment on October 18, 2016 and January 19, 2017. The consent was signed by the client on October 18, 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, 3, 8, and 9 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 28, 2017. Information to be covered will include appropriate type of release, the appropriate release for funding sources, 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 28, 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 eight client records reviewed during the annual licensing inspection conducted on February 7, 2017.
Client # 2 was admitted into treatment on September 21, 2016 and discharged on February 6, 2017. The treatment plan was completed September 21, 2016 and no treatment plan updates were documented.
Client # 5 was admitted into treatment on April 6, 2016 and discharged on June 16, 2016. The treatment plan was completed April 6, 2016 and no treatment plan updates were documented.
Client # 8 was admitted into treatment on September 28, 2016 and discharged on February 6, 2017. The treatment plan was completed September 28, 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 28, 2017. Each staff member will be provided with a copy of our agency's policy and regulations in regard to plan of care and discharge timelines. In addition, staff members who were responsible for charts 2, 5, 8 will correct these deficiencies no later than Feb 28, 2017 where it is relevant and appropriate. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor. |