INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 16, 2013 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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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director.
The findings include:
Five personnel records were reviewed on December 5, 2013. One personnel record pertained to the project director and required documentation of 12 clock hours of annual training. The training year reviewed was from July 1, 2012 through June 30, 2013. The facility failed to document 12 clock hours of annual training for the 2012/2013 training year in personnel record # 1.
Employee # 1 was hired as the project director on July 1, 1978. Employee # 1 only had 10 clock hours of annual training documented for the 2012/2013 training year.
The facility director confirmed the findings.
This is a repeat citation from the February 27 - 28, 2013 licensing inspection.
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Plan of Correction
The Project Director has completed 6.5 hours of training this training year. The Project Director will complete another 5.5 hours of training to meet the 12 hours of training required per this regulation.
It shall be the responsibility of the Project Director to insure 12 hours of training are obtained each training year.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one personnel records.
The findings include:
Five personnel records were reviewed on December 5, 2013. Three personnel records pertained to counselors. One counselor required the completion of 25 clock hours of annual training. Two counselors were new hires and not yet due to complete annual training hours. The training year reviewed was from July 1, 2012 through June 30, 2013. The facility failed to document 25 clock hours of annual training for the 2012/2013 training year in personnel record # 5.
Employee # 5 is a counselor and was hired on August 1,2005. Personnel record # 5 only included documentation of 14 clock hours of annual training for the 2012/2013 training year.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Clinical Supervisors shall be responsible for insuring clinical staff obtain 25 hours of training in the training year. Facility Director shall review training documentation with Clinical Supervisor to insure all training opportunities, internally and externally, are documented to meet this regulation.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through quarterly reviews of employee trainings.
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715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility's physician failed to document in the patient's record the basis for the determination of current dependency and evidence of a one year history of addiction in three of three patient records.
The findings include:
Twelve client records were reviewed on December 16, 2013. Five patients were prescribed Suboxone. These patient records were reviewed for documentation that the physician made a face-to-face determination of whether the individual was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for this determination. The physician failed to document in the patient's record the basis for determination of current dependency and evidence of a one year history of addiction in patient records # 2, 3 and 7.
Patient # 2 was admitted into treatment on September 19, 2013. The physician conducted a face-to-face visit with patient # 2 on October 31, 2013 and prescribed 8 mg/2 mg Suboxone daily. The physician failed to document whether patient # 2 was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for the determination.
Patient # 3 was admitted into treatment on July 26, 2013. The physician conducted a face-to-face visit with patient # 3 on September 30, 2013 and prescribed 12 mg/3 mg Suboxone daily. The physician failed to document whether patient # 3 was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for the determination.
Patient # 7 was admitted into treatment on August 15, 2013. The physician conducted a face-to-face visit with patient # 7 on September 30, 2013 and prescribed 12 mg/3 mg Suboxone daily. The physician failed to document whether patient # 7 was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for the determination.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the February 27 - 28, 2013 licensing inspection.
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Plan of Correction
Clinical Supervisor will review with physicians the requirement to document thoroughly 1 year history of addiction and current opiate dependency in each patient record. Physicians will enter this information in records #2, 3,and 7.
It shall be the responsibility of the Clinical Supervisor to insure this documentation is included in client records through weekly chart supervision.
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709.91(b)(5) LICENSURE Intake and admission
709.91. 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 client records, the facility failed to document a physical examination including the patient's vital signs in three of three client records.
The findings include:
Twelve client records were reviewed on December 16, 2013. Three client records were reviewed for physical examinations. The facility failed to document a physical examination including the patient's vital signs in client records # 2, 3 and 7.
Client # 2 was admitted into treatment on September 19, 2013. A physical examination was completed on October 31, 2013. The physical examination for client # 2 did not include the patient's vital signs.
Client # 3 was admitted into treatment on July 26, 2013. A physical examination was completed on September 30, 2013. The physical examination for client # 3 did not include the patient's vital signs.
Client # 7 was admitted into treatment on August 15, 2013. A physical examination was completed on September 30, 2013. The physical examination for client # 7 did not include the patient's vital signs.
The findings were confirmed by the clinical supervisor.
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Plan of Correction
Clinical Supervisor will review with physicians the requirement to document vital signs in each patient record. Physicians will enter this information in records #2, 3, and 7.
It shall be the responsibility of the Clinical Supervisor to insure this documentation is included in client records through weekly chart supervision.
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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 a review of client records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the client's assets/strengths, support systems, coping mechanisms and negative factors in six of seven client records.
The finding include:
Twelve client records were reviewed on December 16, 2013. Seven client records were reviewed for psychosocial evaluations that included a clinical assessment of the client. The facility failed to document a psychosocial evaluation that included a clinical assessment of the client's assets/strengths, support systems, coping mechanisms and negative factors in client records # 1, 2, 3, 4, 5 and 6.
Client # 1 was admitted into treatment on August 12, 2013. A psychosocial evaluation was completed on August 8, 2013. The psychosocial evaluation for client # 1 did not include a clinical assessment of the client's assets/strengths, support systems and coping mechanisms and only included client reported historical information.
Client # 2 was admitted into treatment on September 19, 2013. A psychosocial evaluation was completed on September 11, 2013. The psychosocial evaluation for client # 2 did not include a clinical assessment of the client's assets/strengths and coping mechanisms and only included client reported historical information.
Client # 3 was admitted into treatment on July 26, 2013. A psychosocial evaluation was completed on July 22, 2013. The psychosocial evaluation for client # 3 did not include a clinical assessment of the client's assets/strengths and coping mechanisms and only included client reported historical information.
Client # 4 was admitted into treatment on September 19, 2013. A psychosocial evaluation was completed on September 11, 2013. The psychosocial evaluation for client # 4 did not include a clinical assessment of the client's assets/strengths and only included client reported historical information.
Client # 5 was admitted into treatment on August 28, 2013. A psychosocial evaluation was completed on August 14, 2013. The psychosocial evaluation for client # 5 did not include a clinical assessment of the client's assets/strengths and negative factors that might affect treatment and only included client reported historical information.
Client # 6 was admitted into treatment on November 7, 2013. A psychosocial evaluation was completed on October 16, 2013. The psychosocial evaluation for client # 6 did not include a clinical assessment of the client's assets/strengths, support systems and coping mechanisms and only included client reported historical information.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the February 13 - 14, 2012 and February 27 - 28, 2013 licensing inspections.
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Plan of Correction
Clinical Supervisor shall review with all clinical staff the requirement to document a clinical assessment of the client's strengths/assets, support system, coping mechanisms and negative factors in a psychosocial evaluation.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision. |