INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16-17, 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 19, 2007.
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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
The individual listed as the clinical supervisor exceeded the maximum permissible caseload for a full time clinical supervisor.
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Plan of Correction
The Clinical Supervisor was promoted to this position on April 1, 2007 and was interviewing potential candidates to replace the counselor position in which she vacated.
A full-time counselor was hired on June 11, 2007. The caseload has been re-assigned to the full-time counselor. At this time, the Clinical Supervisor has no caseload assigned to her. It shall be the responsibility of the Clinical Supervisor to insure all caseload ratios remain in compliance through weekly caseload monitoring. |
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
Mandatory communicable disease training was not documented for employee #3.
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Plan of Correction
Employee #3 training was an oversight on part of the Clinical Supervisor. However, as of this date, is no longer employed at SPHS Behavioral Health.
It shall be the ongoing responsibility of the Clinical Supervisor to review all staff receive mandatory communicable disease training, per regulation. It shall be the responsibility of the Clinical Supervisor to submit all copies of training certificates to the SPHS Inc. Human Resource Department upon completion of training. |
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
Fire extinguisher training was not documented for employees # 2 and 4.
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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 will be retrained and documentation placed in respective Personnel Records.
It shall be the responsibility of the Clinical Supervisor to insure 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 insure ongoing compliance through monitoring of Personnel Records.
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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
Emergency procedures training was not documented for employees # 2 and 4.
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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 will be retrained and documentation placed in respective Personnel Records.
It shall be the responsibility of the Clinical Supervisor to insure all staff continue to be trained on 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.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
No documentation was presented to indicate that the fire alarm system was tested. When the facility is approved for an alternate procedure , documentation must be presented at least annually that the fire alarm system is in operating condition.
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Plan of Correction
SPHS Behavioral Health Latrobe Area Office is located within a professional office building and did not have documentation of the annual fire alarm system test.
Project Director will submit a formal request for an annual test of the fire alarm system to the landlord of this site. Project Director will also request documentation of annual fire alarm tests from landlord. It shall be the responsibility of the Clinical Supervisor to insure the annual fire alarm test and documentation is completed. |
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
The psychosocial evaluation in the one file available for review did not address all required areas (composite picture, coping mechanisms and negative factors).
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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 through clinical supervision and chart reviews.
It shall be the responsibility of the Clinical Supervisor to review all required areas of a psychosocial evaluation and provide examples indicated during the recent Department of Health Licensing visit as meeting this standard with clinical staff. Clinical Supervisor shall insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews.
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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 progress notes did not address group interactions/dynamics.
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Plan of Correction
SPHS Behavioral Health chooses to use individual group notes for each participant in group sessions. Group interactions or dynamics for each member need to be better documented.
It shall be the responsibility of the Clinical Supervisor to review and train staff on the group note documentation, including group member's interaction or group dynamics. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews.
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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 and the manuals at the various locations reviewed contained redundant and contradictory policies and procedures. The general organization of the manual made the review difficult and increased the potential for misunderstanding the intent of various procedures.
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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 contained a listing of the treatment models used. Definitions were not included for each one listed.
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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 definitions of the various treatment models used by SPHS Behavioral Health. It shall be the responsibility of the Clinical Supervisor to insure clinical documentation is consistent with the models as they are defined through clinical supervision and weekly chart reviews.
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709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
No current job description or contract was found for employee # 1.
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Plan of Correction
Employee #1 job descpription was an oversight on the part of the Clinical Supervisor. A signed job description has been placed in Employee #1 Personnel Record.
It shall be the responsibility of the Clinical Supervisor to insure employees sign job descriptions and submit to all copies of job description to the SPHS Inc. Human Resource Department. 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.
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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 of the disclosure was not clearly stated on consents in the files reviewed. The purpose should clearly indicate the reason for the specific information identified on the consent to be released to the person/agency identified.
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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 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 Clinical Supervisor to insure ongoing compliance with this regulation through clinical supervision and ongoing weekly reviews.
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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 documented in each of the records reviewed were lacking in one or more of the required components. The evaluation should provide a picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review all required elements of the psychosocial evaluation as defined in regulation, including but not limited to the negative factors and 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. Clinical Supervisor will insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews.
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709.92(a) 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:
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Observations
Treatment plans in client records reviewed lacked individualized content. Treatment plans found in client records has a generic quality to them. Plans should address the assessed needs of the individual in measurable, realistic terms.
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Plan of Correction
SPHS Behavioral Health makes every effort to develop treatment plans which are clear and individualized and in measurable, realistic terms.
It shall be the responsibility of the Clinical Supervisor to review and provide examples, indicated during the recent Department of Health Licensing visit as meeting this standard, to clinical staff. Clinical Supervisor will insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews.
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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 progress notes did not address the dynamics/interactions during the group sessions.
If 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 group notes for each participant in group sessions. Group interactions or dynamics for each member need to be better documented.
It shall be the responsibility of the Clinical Supervisor to review and train staff on the group note documentation, including group member's interaction or group dynamics. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews.
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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 three of three applicable client records (#2, 3, and 4).
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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 Clinical Supervisor to insure ongoing compliance with the Follow-Up Policy through random supervision of discharged client charts.
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