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Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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SPHS BEHAVIORAL HEALTH
203 SOUTH MAPLE AVENUE
GREENSBURG, PA 15601

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Survey conducted on 01/26/2022

INITIAL COMMENTS
 
This report is a result of an on-site licensure renewal inspection conducted on January 25-26, 2022, 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:
 
Plan of Correction

709.30 (2)  LICENSURE Client rights

§ 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
Observations
Based on a review of client records, the facility's client rights policy failed to include documentation of all required client rights, including that the Program will not deny service to any client based on creed, race, or color.



The finding was reviewed with facility staff during the licensing process.
 
Plan of Correction
The Client Orientation Packet provided to every client at the time of their initial evaluation was amended by the Clinical Director on 1/26/2022 to include the approved nondiscriminatory policy wording, "Our Program will not deny service to any client based on age, ethnicity, race, color, sexual orientation, or national origin, marital status, sex, handicap, or religion/creed. The Program will follow all Federal, State, and Local laws concerning Program services." All new clients will electronically sign an Orientation Packet Checklist in Credible indicating that they received a copy of said packet and Non-Discrimination policy. All previous copies of the orientation packet have been removed from the facility. A digital copy was also sent to all staff to offer to current clients who may have received the previous version.

 
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