INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6 - 7, 2012 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(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
Based on a review of personnel training records and the Staffing Requirements Facility Summary Report form, the facility failed to provide documentation of communicable disease training in four of five personnel training records.
The findings include:
Fourteen personnel training records were reviewed on February 3, 2012. Five personnel training records were reviewed for documentation of communicable disease training. The facility failed to provide documentation of HIV/AIDS training in personnel training records # 9, 12, 13 and 14.
Employee # 9 is a counselor and was hired on May 17, 2010. HIV/AIDS training was due to be completed no later than May 17, 2011. The facility failed to provide documentation of HIV/AIDS training for employee # 9.
Employee # 12 is a support staff and was hired on October 7, 2008. HIV/AIDS training was due to be completed no later than October 7, 2010. The facility failed to provide documentation of HIV/AIDS training for employee # 12.
Employee # 13 is a support staff and was hired on November 30, 2005. HIV/AIDS training was due to be completed no later than November 30, 2007. The facility failed to provide documentation of HIV/AIDS training for employee # 13.
Employee # 14 is a counselor and was hired on January 3, 2011. HIV/AIDS training was due to be completed no later than January 3, 2012. The facility failed to provide documentation of HIV/AIDS training for employee # 14.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the January 20 - 21, 2011 licensing inspection.
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Plan of Correction
Employees 9, 12, 13, 14 will be mandated to attend HIV/AIDS training for 6 hours on May 18, 2012 when the agency holds HIV/AIDS training for all staff.
It shall be the responsibility of the Clinical Supervisors to insure ongoing compliance with this regulation and insure all staff are trained on HIV/AIDS within the required time frame for their respective position. |
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
Based on a review of client records, the facility failed to document a psychosocial evaluation that provided a composite picture of the individual in relationship to the collected historical information in three of four partial hospitalization client records.
Twenty client records were reviewed on February 6 - 7, 2012. Eight client records pertained to the partial hospitalization activity. Four client records were reviewed for psychosocial evaluations. The facility failed to provide a composite picture of the individual in relationship to the collected historical information in client records # 1, 3 and 4.
The findings include:
Client # 1 was admitted into treatment on August 25, 2011. The psychosocial evaluation was completed on August 25, 2011. The personal history was documented on August 26, 2011. The psychosocial evaluation was completed prior to the collection of personal historical information. The facility failed to document a psychosocial evaluation that was based on the collected historical information of the client.
Client # 3 was admitted into treatment on November 10, 2011. The psychosocial evaluation was completed on November 2, 2011. The personal history was documented on November 29, 2011. The psychosocial evaluation was completed prior to the collection of personal historical information. The facility failed to document a psychosocial evaluation that was based on the collected historical information of the client.
Client # 4 was admitted into treatment on October 14, 2011. The psychosocial evaluation was completed on September 29, 2011. The facility failed to provide a composite picture of the individual in relationship to the collected historical information.
The facility director and clinical supervisor were interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisors to review the appropriate completion of the psychosocial evaluation and development of a composite picture with clinical impressions of clients. In addition, the Clinical Supervisors will review the process of completing the personal history before completing a psychosocial evaluation with clinical staff.
It shall be the responsibility of the Clinical Supervisors to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
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
Based on a review of client records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the client in four of seven outpatient client records.
The findings include:
Twenty client records were reviewed on February 6 - 7, 2012. Twelve client records pertained to the outpatient activity. Seven client records were reviewed for psychosocial evaluations. The facility failed to document a psychosocial evaluation that included a clinical assessment of the client in client records # 10, 12, 13 and 14.
Client # 10 was admitted into treatment on September 26, 2011. The psychosocial evaluation was completed on September 22, 2011. The psychosocial evaluation did not include a clinical assessment of the client and only included client historical information.
Client # 12 was admitted into treatment on July 28, 2011. The psychosocial evaluation was completed on July 25, 2011. The psychosocial evaluation did not include a clinical assessment of the client and only included client historical information.
Client # 13 was admitted into treatment on August 17, 2011. The psychosocial evaluation was completed on August 15, 2011. The psychosocial evaluation did not include a clinical assessment of the client and only included client historical information.
Client # 14 was admitted into treatment on August 11, 2011. The psychosocial evaluation was completed on August 10, 2011. The psychosocial evaluation did not include a clinical assessment of the client and only included client historical information.
The facility director and clinical supervisor were interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisors to review the requirements of the psychosocial evaluations including clinical impressions and assessment.
It shall be the responsibility of the Clinical Supervisors to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
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
Based on a review of client records, the facility failed to document the development of an individual treatment and rehabilitation plan with the client, as per facility policy, in two of seven outpatient client records.
The findings include:
Twenty client records were reviewed on February 6 - 7, 2012. Twelve client records pertained to the outpatient client activity. Seven client records were reviewed for individual treatment and rehabilitation plans. Per facility policy, an individual treatment and rehabilitation plan will be developed with the client within 30 days of admission. The facility failed to document the development of an individual treatment and rehabilitation plan with the client in client records # 13 and 15.
Client # 13 was admitted into treatment on August 17, 2011. An individual treatment and rehabilitation plan was due to be completed no later than September 17, 2011. The counselor completed the treatment plan on September 8, 2011. The client did not sign the treatment plan until October 10, 2011. Per review of the record of services provided, the client was present in treatment during this time period. The facility failed to document the development of an individual treatment plan with the client.
Client # 15 was admitted into treatment on August 24, 2011. An individual treatment and rehabilitation plan was due to be completed no later than September 24, 2011. The counselor completed the treatment plan on September 29, 2011. The client did not sign the treatment plan until October 29, 2011. Per review of the record of services provided, the client was present in treatment during this time period. The facility failed to document the development of an individual treatment plan with the client.
The facility director and clinical supervisor were interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisors to review the policy regarding individual treatment plan development and required time frames, namely within 30 days per agency policy.
It shall be the responsibility of the Clinical Supervisors to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |