INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 12, 13, and 14, 2008 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 March 18, 2008.
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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
Based on a review of administrative documentation and the staffing requirements facility summary report, the facility failed to assign a full time clinical supervisor. There were over 11 full time equivalent counselors working at this facility, but a full time clinical supervisor had not been assigned.
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Plan of Correction
On March 1, 2008, Lead Therapist was promoted to full-time Clinical Supervisor to meet this regulation. The Clinical Supervisor is directly supervised by the Facility Director. The Facility Director shall be responsible for insuring there is a full-time clinical supervisor for this facility on an ongoing basis. |
704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on review of the policy and procedure manual during the licensing inspection of February 11, 2008, the facility did not include time frames for the completion of the components of the staff development policy and procedure.
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Plan of Correction
Project Director shall rewrite the policy and procedure regarding Staff Development Program to include time frames for the completion of the components.
It shall be the responsibility of the Project Director to insure all policy and procedures are accurate and comply with regulations through annual reviews of all policy and procedures.
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705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant walk through of the building during the licensing inspection of February 11, 2008, the facility failed to maintain all structures of the facility to be free from any danger to health and safety. During the walk through the ceiling tile in office's and hallways, specifically counselor's offices, group rooms and the conference room, were stained from water and/or still wet from water leaks. In addition, carpet was ripping at the seams, causing the potential for tripping hazards.
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Plan of Correction
It shall be the responsibility of the Project Director to contact landlord for facility to have ceiling tiles replaced and carpet issues resolved.
It shall be the responsibility of the Clinical Supervisor to notify the Project Director immediately when any Physical Plant issue occurs and to monitor facility on a regular basis for ongoing compliance with all Physical Plant regulations.
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709.82(a)(1) LICENSURE Treatment and rehabilitation services
709.82. 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 review of client record during the licensing inspection of February 11, 12, and 13, 2008, the facility failed to document treatment and rehabilitation plans that included short and long term goals that were realistic and stated with measurable criteria. Action plan steps on the treatment plans failed to address how and what the client is to do relative to the issues identified on the client treatment plans. This was evident in three client records reviewed, specifically client records # 11, 12, and 13.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff on treatment and rehabilitation plans, specifically action steps that address how and what the client is to do relative to the issues identified on the client treatment plans.
It shall also be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision.
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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
Based on review of client records during the licensing inspection on February 11,12, and 13, 2008, the group progress notes failed to include complete data, and assessments of the group process and failed to demonstrate consistency with the treatment plan objectives in each of the individual client records reviewed. Group notes were incomplete in one of three client records reviewed, specifically client record #12.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff regarding required elements of a group note including complete data, assessment of the group process, consistency with treatment plan objectives, and all other required elements of a progress/group note.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision.
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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
Based on review of the policy and procedure manual during the licensing inspection of February 11, 2008 the project director failed to remove contradictory policies and procedures when the manual was last updated. Specific polices and procedures containing contradictory language included the outpatient treatment process under Phase 2 for Aftercare plans, treatment plan updates, medical histories, psychosocial history/assessment, and the psychosocial evaluation/summary. Text in the outpatient manual contained polices and procedures which contradicted those in the main manual. The specific policy and procedure included psycho-social history, addictive history, treatment contract, problem list, initial treatment plan, physical examination form, and medical history.
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Plan of Correction
Project Director shall again review and remove all contradictory policies and procedures and contradictory language throughout the manuals. Project Director will again replace with concise and accurate policies and procedures.
It shall be the responsibility of the Project Director to insure ongoing compliance with this regulation through annual reviews of the policy and procedure manuals.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of the policy and procedure manual during the licensing inspection of February 11, 2008, the annual audit was in draft form for the financial year ending June 30, 2007. The final audit has yet to be completed.
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Plan of Correction
In the future, SPHS Behavioral Health will provide documentation that we meet eligible criteria under the Circular OMB133 or "Single Audit Act" and will be eligible for an extension on the complete final audit.
It shall be the responsibility of the Project Director to insure ongoing compliance with this regulation and insure this audit is completed within the time frames of the Circular OMB133 or "Single Audit Act". |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on review of client records during the licensing inspection of February 11, 2008, the facility failed to document a notification of termination in one out of one client records reviewed, specifically client record # 11.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff regarding Notification of Termination when involuntarily discharging a client from treatment.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart review and clinical supervision.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records during the licensing inspection of February 11, 2008, the facility failed to document a complete personal history in 6 out of 8 client records reviewed, specifically client records # 1, 2, 4, 6, 7 and 8. The personal histories were incomplete in the following areas: family history(client records # 1, 2, 4, 6, 7 and 8), legal histories (client records #1) employment history (client records # 4, 6, 7 and 8) educational history (client records # 4, 6, 7 and 8) recreational history (client record # 1, 2, 4, 7 and 8) and sexual histories (client record # 1, 2, 4, 6, 7 and 8).
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff regarding the documentation of complete personal histories, specifically in the areas of family, legal histories, employment, educational, recreational, and sexual histories.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart review 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 review of client records during the licensing inspection of February 11, 2008, the facility failed to document treatment and rehabilitation plans that include realistic and measurable short and long term goals in the client records reviewed, specifically client records # 1, 2, 4, 5, 6 and 8. Action plan steps failed to include how, and what the client was to do relative to the "identified" action steps and objectives.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff on treatment and rehabilitation plans, specifically action steps that address how and what the client is to do relative to the issues "identified" action steps.
It shall also be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision
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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
Based on review of client records during the licensing inspection of February 11, 2008, the group progress notes failed to include a complete data and assessment section. Refer to client records # 1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff regarding required elements of a group note including complete data and assessment of the group process. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on review of client records during the licensing inspection of February 11, 2008, the facility failed to document when the discharge summary was completed. A completion date was not included on the discharge summary, making it impossible to determine if the material was completed in a timely manner. Refer to client records # 5, 8, 9 and 10.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff regarding the documentation of the date a discharge summary is completed.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart reviews and clinical supervision.
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