INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 24, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
The facility failed to obtain an informed and voluntary consent in eight of ten client records reviewed on January 24, 2019.
Client records # 1, 2, 3, 4, 5, 6, 7 and 9. The records documented a release of information for a funding agency. The release included specific information which exceeded the limits of 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Supervisor distributed timeline handouts to all staff to ensure compliance adherence with documentation deadlines. At the very top of the handout, the Plan Of Care/Treatment Plan section outlines the following due dates and update frequencies:
- At admission
- Change in modality (stepping down from group, into group, level of care change, Etc.)
- If the individual has met a goal or if a goal needs updated for any reason
- Mental Health 90/120 days (a plan of care must be done on the due date ? even if a discharge is pending).
- Drug and Alcohol Partial 20/30 days (a plan of care must be done on the due date ? even if a discharge is pending).
- Drug and Alcohol IOP or OP 45/60 days (a plan of care must be done on the due date ? even if a discharge is pending).
The staff meeting was documented and filed and staff signed the minutes verifying receipt of the information.
The management team added a required field in progress notes so that treating clinician must click on a box verifying that an active and valid treatment plan exists in order to submit their service provision documents. Moreover, the Program Supervisor will review client charts randomly and during supervision to ensure clinicians' timely submissions of treatment plan updates. The corrective action date will be in effect as soon as 2/8/19. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
The facility failed to ensure the client was provided with individual counseling at least twice weekly in one of three client records reviewed on Janaury 24, 2019.
Client record # 7 was admitted on December 15, 2018 and was still an active client at the time of the licensing review. The record documented only two individuals scheduled, December 27, 2018 and January 2, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In a mandatory staff meeting, the Program Supervisor will explain that clients in the partial hospitalization level of care are to receive a minimum of 2 individual counseling sessions per week. Therapists who have clients in partial hospitalization level of care on their caseload will share client(s) with Program Supervisor at the beginning of individual supervision so the Program Supervisor can ensure that the identified client(s) are scheduled for at least 2 individual sessions per week. The corrective action plan will be in effect on Thursday, March 7, 2019. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to document that each female patient is fully informed of the possible risk to her or her unborn child in two of two patient records reviewed on January 24, 2019.
Client records # 1 and 4 did not document that the female patient was fully informed of the possible risk to her or her unborn child.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Supervisor created an educational section outlining all potential risks to an individual of child-bearing age including the risks to her unborn child. This educational section will be integrated into initial intake assessment paperwork. The Program Director met with the Administrative Assistant to ensure that the form had been added to all intake paperwork. The intake assessor will summarize the information to all applicable clients and obtain client's signature verifying their understanding of the potential risks associated with MAT options. The process will be in place on 2/28/2019. |
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 and rehabilitation plans were reviewed and updated at least every 60 days in three of six client records reviewed on January 24, 2019.
In client record # 4, a treatment plan update was due to be completed by November 13, 2018. The treatment plan update was completed on December 6, 2018.
In client record # 9, a treatment plan update was due to be completed by November 13, 2018. A treatment plan update was not documented in the client record at the time of the client's discharge on December 6, 2018.
In client record # 10, a treatment plan update was due to be completed by October 13, 2018. A treatment plan update was not documented in the client record at the time of the client's discharge on November 2, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Supervisor distributed timeline handouts to all staff to ensure compliance adherence with documentation deadlines. At the very top of the handout, the Plan Of Care/Treatment Plan section outlines the following due dates and update frequencies:
- At admission
- Change in modality (stepping down from group, into group, level of care change, Etc.)
- If the individual has met a goal or if a goal needs updated for any reason
- Mental Health 90/120 days (a plan of care must be done on the due date ? even if a discharge is pending).
- Drug and Alcohol Partial 20/30 days (a plan of care must be done on the due date ? even if a discharge is pending).
- Drug and Alcohol IOP or OP 45/60 days (a plan of care must be done on the due date ? even if a discharge is pending).
The staff meeting was documented and filed and staff signed the minutes verifying receipt of the information.
The management team added a required field in progress notes so that treating clinician must click on a box verifying that an active and valid treatment plan exists in order to submit their service provision documents. Moreover, the Program Supervisor will review client charts randomly and during supervision to ensure clinicians' timely submissions of treatment plan updates. The corrective action date will be in effect as soon as 2/8/19. |