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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704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, Personnel record and an interview with the Facility Director, the facility failed to document that each clinical supervisor completed at least 12 hours of annual training.
The project's training year is from July 1 through June 30 and the 2019/2020 training year was reviewed for this licensing inspection. Employee, #3, hired as a clinical supervisor on January 16, 2016, had documentation of 3 training hours for the 2019/2020 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training hour tracking logs will be created and distributed for all program staff. The Program Director will keep a file for Program Supervisor training hours. The Program Supervisor will be responsible for tracking all staff training hours in the program. Upon approval, this can go into effect as early as April 1, 2021. |
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 5 counselor caseloads.
Counselor #5 works 32 hours at the facility with 10 of the hours being dedicated to D/A clients. The facility's work week is 37.5 hours, therefore, 10/37.5 = .27 FTE. Counselor #5's D/A caseload is currently 10 active D/A clients. Therefore, 10/.27 = 37.03 or 37/1, which exceeds the maximum of 35/1.
Counselor #6 works 12 hours at the facility with 4 of the hours being dedicated to D/A clients. The facility's work week is 37.5 hours, therefore, 4/37.5 = .11 FTE. Counselor #6's D/A caseload is currently 4 active D/A clients. Therefore, 4/.11 = 36.36 or 37/1, which exceeds the maximum of 35/1.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the annual inspection conducted on February 20, 2020.
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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 6 of 7 client records.
Client #1 was admitted on August 13, 2020 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 September 24, 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 June 30, 2020 and discharged on November 17, 2020. " Verbal consent " was observed to be documented on releases of information documented in the client record.
Client #5 was admitted on May 5, 2020 and discharged September 10, 2020. " Verbal consent " was observed to be documented on releases of information documented in the client record.
Client #6 was admitted on June 16, 2020 and discharged January 13, 2021. " Verbal consent " was observed to be documented on releases of information documented in the client record.
Client #7 was admitted on September 1, 2020 and discharged January 26, 2021. " 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 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. |
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 6 of 7 client records.
Client #1 was admitted on August 13, 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 #3 was admitted on September 24, 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 June 30 30, 2020 and discharged on November 17, 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 May 5, 2020 and discharged September 10, 2021. " 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 June 16, 2020 and discharged January 13, 2021. " 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 #7 was admitted on September 1, 2020 and discharged January 26, 2021. " 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
All consents will be completed at intake in person upon an individual's admission into the Drug and Alcohol program. The electronic health record (Credible) will capture physical signatures containing time and date stamps associated with the physical signature obtained. The same in person stipulation will apply to consents that are completed with active clients upon their return to the office. The corrective action will go into effect April 1, 2021 upon approval. The action will be mandated by the Program Supervisor and carried out by the direct service staff team. |
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 a review of client records, the facility failed to document treatment plan updates at least every 60 days in 3 of 7 client records.
Client #2 was admitted on October 8, 2020 and is currently an active client. A treatment plan was developed on October 8, 2020. Treatment plan updates were due to be completed December 8, 2020 and February 8, 2021. There were no treatment plan updates documented in client record #2.
Client #3 was admitted on September 24, 2020 and is currently an active client. A treatment plan was developed on September 24, 2020. A treatment plan update was due to be completed by November 24, 2020. One treatment plan update dated January 7, 2021 was documented in client record #3.
Client #7 was admitted on September 1, 2020 and discharged on January 26, 2021. A treatment plan was developed on September 1, 2020. Treatment plan updates were due to be completed November 1, 2020 and January 1, 2021. There were no treatment plan updates documented in client record #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan tracker sheets have been developed so that expiration dates on all clients' treatment plans can be referenced every work day. The Program Supervisor will distribute treatment plan tracker sheets to all staff who will be required to keep visible at their work space every business day to proactively account for approaching treatment plan expiration dates. Upon approval, the plan will be executed as early as April 1, 2021. |