INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection beginning on February 8, 2021 and concluding on February 19, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to maintain the outpatient counselor caseloads at or below 35/1 in 2 of 17 counselor caseloads.
Counselor #10 works 48 hours at the facility with 42 of the hours being dedicated to D/A clients. The facility's work week is 37.5 hours, therefore, 42/37.5 = 1.12 FTE. Counselor #10's D/A caseload is currently 69 active D/A clients. Therefore, 69/1.12 = 61.60 or 62/1, which exceeds the maximum of 35/1.
Counselor #11 works 37.5 hours at the facility with 32.5 of the hours being dedicated to D/A clients. The facility's work week is 37.5 hours, therefore, 37.5/32.5 = .87 FTE. Counselor #11's D/A caseload is currently 68 active D/A clients. Therefore, 68/.87 = 78.16 or 79/1, which exceeds the maximum of 35/1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will present updates on their caseloads at weekly D&A Clinical meetings and review caseloads weekly with Clinical Supervisor. For counselors that cannot attend the weekly Clinical meeting, Supervisor will provide a summary of their caseload that counselor will review. Clinical Supervisor will continue to explore options for additional recruitment of staff. If counselor ratios are maxing out across the board, Program Supervisor will notify Program Director who will put a hold on program referrals until staffing patterns can support. Upon approval, the process will begin April 1, 2021. |
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
Based on a review of client records, the facility failed to document a written informed and voluntary consent from the client for the disclosure of information contained in 5 of 8 client records.
Client #1 was admitted on January 7, 2021 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record.
Client #3 was admitted on July 9, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record.
Client #4 was admitted on April 30, 2020 and discharged on August 31, 2020. " Verbal consent " was observed to be documented on releases of information documented in the client record.
Client #5 was admitted on January 21, 2021 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record.
Client #6 was admitted on July 27, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning April 1st, all initial assessments will take place in person to obtain appropriate consents with client signatures. This will ensure that each client has all the information they need regarding their client record with clear documentation that they were given information on what can be obtained/released from their medical record. The process will be mandated by the Program Supervisor and carried out by the direct service staff upon approval. It can start as early as April 1, 2021. |
709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document a written informed and voluntary consent from the client, which included a dated signature, for the disclosure of information contained in 5 of 8 client records.
Client #1 was admitted on January 7, 2021 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record. There was no client signature documented on these releases.
Client #3 was admitted on July 9, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record. There was no client signature documented on these releases.
Client #4 was admitted on April 30, 2020 and discharged on August 31, 2020. " Verbal consent " was observed to be documented on releases of information documented in the client record. There was no client signature documented on these releases.
Client #5 was admitted on January 21, 2021 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record. There was no client signature documented on these releases.
Client #6 was admitted on July 27, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record. There was no client signature documented on these releases.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning April 1st, all intake assessments for new clients will be scheduled in person. All consents will be physically signed at intake. Current, active clients will have new consents submitted with physical signature upon returning to office for their first onsite appointment. For current, active clients who have been conducting telehealth, they will have to attend at least 1 session per month to ensure physical signatures can be obtained and up to date. The corrective action will commence as soon as approved and will take effect as early as April 1, 2021. This will be stipulated by the Program Supervisor and become requirements carried out be direct service staff from April 1, 2021 onward. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of client records, the facility failed to document verification that the client reached 18 years of age, prior to the administration of an agent in one of four client records.
Client #5 was admitted on January 21, 2021 and is currently active. Client #5 was initially prescribed buprenorphine on January 25, 2021. There was no documentation of the verification of the client's age in client record #5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program has a Medical Assistant who has been trained in obtaining consent from clients for Buprenorphine treatment and obtaining verification of age prior to the evaluation. Clinical Supervisor will review each chart to ensure compliance. Additionally the Medical Assistant will be give the developed Medication Assisted Treatment checklist to reference. This process can commence April 1, 2021 upon approval. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of client records, the facility failed to document verification of the clients identity, including name, address and date of birth prior to the administration of an agent in one of four client records.
Client #5 was admitted on January 21, 2021 and is currently active. Client #5 was initially prescribed buprenorphine on January 25, 2021. There was no documentation of the verification of the client's identity in client record #5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program has a Medical Assistant who has been trained in obtaining consent from clients for Buprenorphine treatment and obtaining verification of age prior to the evaluation. Clinical Supervisor will review each chart to ensure compliance. Additionally the Medical Assistant will be give the developed Medication Assisted Treatment checklist to reference. This process can commence April 1, 2021 upon approval. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document a consent to buprenorphine treatment prior to the administration of an agent in two of four client records.
Client #5 was admitted on January 21, 2021 and is currently active. Client #5 was initially prescribed buprenorphine on January 25, 2021. There was no documentation of a signed buprenorphine consent to treatment in client record #5.
Client #8 was admitted on March 19, 2020 and discharged January 27, 2021. Client #8 was initially prescribed buprenorphine on March 30, 2020. There was no documentation of a signed buprenorphine consent to treatment in client record #8.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Photo identification will be collected and scanned into client charts at the time of in person initial intake assessment. A Medication Assisted Treatment Checklist will also be utilized at the time of MAT Evaluation, which will review and ensure that identification is scanned into the chart prior to MAT assessment. The MAT developed by the Program Supervisor will be distributed for direct service staff use, and it will be incorporated into the Medication Assisted Treatment evaluation process beginning April 1, 2021. |