INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 10-14, 2009 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 and a plan of correction is due on August 7, 2009.
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of employee records during the onsite licensing inspection of August 10-14, 2009, the facility failed to document the required period of direct supervision for each counselor assistant.
The findings included:
At the time of the onsite inspection seven employee personnel records were reviewed. Employee # 2 did not meet the educational requirements for the position of counselor. This employee was required to be in the counselor assistant position and undergo three months of direct observation. During an interview with the facility director on August 10, 2009 she acknowledged that the educational requirements were not met by that employee and that the employee was only given close supervision rather than direct observation during the first three months of employment as a counselor assistant.
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Plan of Correction
Facility Director will instruct the Clinical Supervisor to conduct direct observation of Counselor Assistant (Employee #2) for a 3 month period to include September through November 2009. Clinical Supervisor will document all direct observations and insure ongoing compliance with this standard by documenting and submitting Supervision Logs to Facility Director. Facility Director will review and submit to Human Resources for placement in Personnel File. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the agency policy and procedure materials and the agency training plan, the facility failed to document an overall agency training plan to address the training needs for the 2009-2010 training year.
The findings included :
Agency policy as documented, requires that a training plan be documented on a fiscal year basis. The specifics of documentation as spelled out in agency policy required that the plan be documented in a monthly calendar year format for the fiscal year. While it is acknowledged that this is an acceptable form of documentation, the calendar must be kept current in order to comply with the policy as stated and the intent of this regulation. The calendar presented at the time of the inspection only included dates through the end of June 2009. No training sessions were documented at the time of the inspection on August 11, 2009 for the 2009-2010 training year.
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Plan of Correction
Project Director will establish an overall agency plan to meet agency training needs for FY 2009-2010. It shall be the responsibility of the Project Director to insure the completion of the overall agency training plan on an annual basis.
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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 the documentation provided on the staffing self report form and a review of the employee personnel records during the onsite inspection of August 10-14, 2009, the facility failed to ensure that each caseload remained at or below the 35:1 ratio.
The findings included:
Seven employee records were reviewed during the onsite inspection. One record (#2) was that of a counselor assistant who did not receive the required period of direct observation. As a result her hours could not be factored into the staff to client ratio resulting in a 15:0 ratio for her caseload.
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Plan of Correction
Clinical Supervisor will conduct direct observation of Counselor Assistant (Employee #2) for 3 month period of September through November 2009. Clinical Supervisor will insure through direct observation the counselor assistant caseload is managed and treatment is provided according to agency policy and procedures.
It shall be the responsibility of the Clinical Supervisor to insure all counselor caseloads are at the required 35:1 ratio or below through weekly caseload monitoring.
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704.12(b) & (c) & (d) LICENSURE Counselor Asst/Exceptions
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(b) Counselor assistants. Counselor assistants may be included in determining FTE ratios when the counselor assistant is eligible for a caseload.
(c) Exemption for transitional living. Specific client/staff ratios are not required for transitional living facilities.
(d) Exceptions. A project director may submit to the Department a written petition requesting an exception to the client/staff and client/counselor ratios in this section. The petition shall describe how the characteristics of the program and its client mix support the request for the exception and shall be approved by the governing body. Granting the petition shall be at the discretion of the Department. Long-term residential facilities and halfway houses which include a client's participation in schooling or employment as part of a treatment day are examples when requests for exceptions will be considered.
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Observations
Based on the review of the employee records during the onsite inspection of August 10-14, 2009, the facility failed to comply with the requirements for supervision of each counselor assistant resulting in one counselor having to be factored out of the staff to client caseload computation.
The findings included:
The record of one counselor assistant who was required to undergo three months of direct observation was reviewed during the onsite inspection . Employee # 2 was supervised at the close supervision level, but should have received supervision at the direct observation level. As a result the clinical hours contributed by her could not be counted in the computation of the staff to client caseload.
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Plan of Correction
Clinical Supervisor will conduct direct observation of Counselor Assistant (Employee #2) for 3 month period of September through November 2009. Clinical Supervisor will insure through direct observation the counselor assistant caseload is managed and treatment is provided according to agency policy and procedures.
It shall be the responsibility of the Clinical Supervisor to insure all counselor caseloads are at the required 35:1 ratio or below through weekly caseload monitoring.
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709.81(b)(5) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of the agency policy and procedure manual and the client records during the onsite licensing inspection of August 13, 2009, the facility failed to adhere to written agency policy regarding documentation of a physical examination in applicable records.
The findings included:
During the onsite licensing inspection two records were reviewed at this level of care. According to written agency policy each client is asked to get a physical examination and return the completed form within 15 days of admission. Client # 7 had an admission date of 7/10/09 and client # 8 had an admission date of 7/6/09. Both clients were in treatment at the time of the inspection on August 13, 2009. Neither record had documentation of a physical examination.
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Plan of Correction
Project Director and Facility Director will removed and revised the Policy and Procedure and narrative program description regarding the requirement for Physical examinations for partial hospitalization. It shall be the responsibility of the Project and Facility Directors to insure Policy and Procedures are accurate and appropriate through annual reviews. |
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 the review of client records during the onsite licensing inspection of August 10-14, 2009, the facility failed to document psychosocial evaluations which documented a composite 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 in two of two client records.
The findings included:
Two client records were reviewed during the onsite inspection of August 10-14, 2009. Each was required to have a complete psychosocial evaluation. Coping mechanisms were not documented in client record # 8. The composite 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 was not documented in client records # 7 and 8.
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Plan of Correction
Facility Director and Clinical Supervisor will review and train clinical staff on appropriate completion of psychosocial evaluations and development of a composite picture of the individual, specifically but not limited to, the relationship of all collected information in order to identify possible relationships, conditions and causes leading to the client's current situation.
It shall be the responsibility of the Clinical Supervisor to insure psychosocial evaluations are complete and provide a composite picture through weekly chart and clinical supervision.
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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
Based on the review of personnel records during the onsite licensing onsite licensing inspection of August 10-14, 2009, the facility failed to document current job descriptions in three of seven personnel records.
The findings included:
Seven personnel records were reviewed during the onsite licensing inspection. Record # 5 did not have a job description documented in the record. Records # 6 and 7 did not have current job descriptions documented in the employee records.
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Plan of Correction
Clinical Supervisor will request written job descriptions for Employees 5, 6, and 7 from Human Resource Department and have staff sign and place in Personnel Files. It shall be the responsibility of the Human Resource Director and Clinical Supervisor to insure all staff have job descriptions and copies are maintained in personnel files. |
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 the review of client records during the onsite licensing inspection of August 10-14, 2009, the facility failed to document psychosocial evaluations which documented a composite 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 in eight of eight client records.
The findings included:
Eight client records were reviewed during the onsite inspection of August 10-14, 2009. Each was required to have a complete psychosocial evaluation . Client strengths were not documented in record 7. Coping mechanisms were not documented in record # 8. The composite 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 was not documented in client records # 1, 2, 3, 4,5 or 6.
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Plan of Correction
Facility Director and Clinical Supervisor will review and train clinical staff on appropriate completion of psychosocial evaluations and development of a composite picture of the individual, specifically but not limited to, the relationship of all collected information in order to identify possible relationships, conditions and causes leading to the client's current situation, and strengths and coping mechanisms.
It shall be the responsibility of the Clinical Supervisor to insure psychosocial evaluations are complete and provide a composite picture through weekly chart and clinical supervision.
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709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on the review of client records during the onsite licensing inspection of August 11-12, 2009, the facility failed to document measurable goals on each treatment plan reviewed in two of six client records.
The findings included:
During the onsite inspection, six client records were reviewed at this level of care. Client record # 3 documented only one goal statement which consisted of a type and frequency of service to be offered ( Phase I /2 times per week). The treatment plan documented in client record # 5 had no D&A treatment goals identified on the plan.
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Plan of Correction
Facility Director and Clinical Supervisor will review and train clinical staff regarding appropriate measurable goals on treatment plans and accurate documentation of type and frequency on a treatment plan.
It shall be the responsibility of the Clinical Supervisor to insure that measurable goals are identified and type and frequency are appropriately documented on treatment plans through weekly chart and clinical supervision.
In addition, treatment plan updates will be completed with each of the two individual clients to accurately reflect drug and alcohol goals and appropriate goal statements for identified problems. Type and frequency of treatment will be identified in it's respective place on the treatment plan update. The Clinical Supervisor will insure treatment plan updates are completed on these 2 cases and all treatment plans meet the requirements of this standard through weekly chart and clinical 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
Based on the review of client records during the onsite licensing inspection of August 10-14, 2009, the facility failed to document treatment plan updates in 2 of 4 client records.
The findings included:
Eight client records were reviewed during the licensing inspection . Four of these were required to have treatment plan updates documented. Records # 2 & 5 did not have treatment plan updates documented as specified in both the regulation and written agency policy and procedure.
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Plan of Correction
Facility Director and Clinical supervisor will review and train clinical staff regarding the requirement to update treatment plans at least every 60 days.
It shall be the responsibility of the Clinical Supervisor to insure psychosocial evaluations are complete and provide a composite picture through weekly chart and clinical supervision
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records during the onsite licensing inspection of August 10-14, 2009, the facility failed to document case consultations quarterly in two of two client records.
The findings included:
Eight client records were reviewed during the onsite licensing inspection. Two of these were required to have case consultations documented. Case consultations were not documented in client records # 5 & 6. Client record # 5 had an admission date listed in the record as 3/4/09, as of the inspection date of 8/12/09, no case consultation was documented. Client record # 6 had an admission date documented of 1/22/09 with the discharge date noted as 5/9/09. No case consultation was documented in the record.
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Plan of Correction
Facility Director and Clinical supervisor will review and train clinical staff regarding the requirement of quarterly case consultation.
It shall be the responsibility of the Clinical Supervisor to insure quarterly case consultations are completed and through weekly chart and clinical supervision.
The 2 cases cited are discharged cases and cannot be corrected to meet this plan of correction. The above noted plan of correction will be implemented and the Clinical Supervisor shall be responsible for insuring all active cases have a documented case consultations quarterly through weekly chart and clinical supervision. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records during the onsite licensing inspection of August 10-14, 2009, the facility failed to document aftercare plans in each applicable record which included a contact person and goals based on the progress achieved during treatment in one of two client records.
The findings included:
Eight client records were reviewed during the onsite inspection. Two of these were required to include documentation of aftercare plans. Client record # 3 did not include documentation of drug and alcohol related goals on the aftercare plan.
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Plan of Correction
Facility Director and Clinical Supervisor will review and train clinical staff regarding the appropriate development and documentation of aftercare plans including but not limited to appropriate goals related to treatment progress and time frames for completing aftercare goals. In addition, staff will be trained on the policy to begin developing aftercare plans during the last month of treatment.
It shall be the responsibility of the Clinical Supervisor to insure aftercare plans are completed thoroughly and accurately, when applicable, and through weekly chart and clinical supervision.
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