INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 17, 2018 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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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
The facility failed to document that a fire alarm or smoke detector was activated during each drill and there was no documentation that the Department had approved an alternative procedure.
Fire drill logs were reviewed on January 17, 2018 for the months of February through December, 2017. All fire drills were missing documention that a fire alarm or smoke detector was activated during each drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program supervisor will conduct monthly fire drills by setting off the fire alarm or the smoke detector. The program supervisor will document each fire drill to include, at a minimum. the date of the fire drill, the amount of time to evacuate the program area, the number of individuals who participated in the fire drill and what device was used to conduct the fire drill.
The program director will review the fire drill log on a quarterly basis to ensure compliance with the regulations.
The program director will submit any necessary paperwork to the Department if the agency chooses an alternative procedure be approved.
The completion date for this plan of correction is 3/14/2018
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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
The facility failed to document that the treatment rehabilitation plans were reviewed every 60 days in two of seven client records reviewed on January 17, 2018.
Client # 2 required a treatment plan update be completed by October 25, 2017. The plan was completed on November 2, 2017.
Client #7 required a treatment plan update be completed by July 22, 2017. There was no treatment plan update documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program supervisor will retrain all staff to complete the treatment rehabilitation plans within the 60 day time frame.
The program supervisor will randomly review client charts and staff schedules to ensure timely completion of the rehabilitation plans.
The program director will randomly review charts on a quarterly basis to ensure compliance with the regulations.
The target date to complete this deficiency will be 3/14/2018. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The facility failed to document that counseling services were provided according to the individual treatment and rehabilitation plan in two of seven records reviewed on January 17, 2018.
Services were not documented as stated in the treatment plans in records # 6 and 7.
The treatment plan for client # 6 documented that the client was to receive 1 individual session a week for the period of June 26, 2017 to August 8, 2017. No individual sessions were documented for the weeks of July 2, July 16 and July 30, 2017.
The treatment plan for client # 7 documented that the client was to receive 1 individual session a week for the period of May 2, 2017 through discharge on August 3, 2017. There were no individuals documented for the weeks of June 4, 18 and 25, 2017. There were no individuals documented for the month of July 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program supervisor will retrain staff to ensure that all clients are receiving the level of counseling as indicated on their treatment and rehabilitation plan.
The program staff will update the clients treatment and rehabilitation plans to indicate any change in the level of service delivery.
The program supervisor will conduct random chart reviews on a quarterly basis to ensure clients are receiving the level of counseling services as indicated on their plans.
The program director will randomly check client charts on a quarterly basis to ensure compliance.
The target date for completion is 3/14/2018.
3/14/2018 |