INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 22, 2012 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel training records and the Staffing Requirements Facility Summary Report form, the facility failed to provide documentation of communicable disease training in one of one personnel training records.
The findings include:
Six personnel training records were reviewed on February 3, 2012. One personnel training record was reviewed for documentation of communicable disease training. The facility failed to provide documentation of TB/STD training in personnel training record # 6.
Employee # 6 is a counselor and was hired on July 1, 2010. TB/STD training was due to be completed no later than July 1, 2011. The facility failed to provide documentation of TB/STD training for employee # 6.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Employee #6 is required to attend the TB/STD training on May 18, 2012 in Washington County.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through regular reviews of employee training plans. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document the development of an individual treatment and rehabilitation plan with the client, as per facility policy, in two of five outpatient client records.
The findings include:
Ten outpatient client records were reviewed on February 22, 2012. Five client records were reviewed for individual treatment and rehabilitation plans. Per facility policy, an individual treatment and rehabilitation plan will be developed with the client within 30 days of admission. The facility failed to document the development of an individual treatment and rehabilitation plan with the client in client records # 2 and 5.
Client # 2 was admitted into treatment on November 15, 2011. An individual treatment and rehabilitation plan was due to be completed no later than December 15, 2011. The counselor completed the treatment plan on December 9, 2011. The client did not sign the treatment plan as of February 22, 2012. Per review of the record of services provided, the client was present in treatment during this time period. The facility failed to document the development of an individual treatment plan with the client.
Client # 5 was admitted into treatment on November 1, 2011. An individual treatment and rehabilitation plan was due to be completed no later than December 1, 2011. The counselor completed the treatment plan on December 6, 2011. The client did not sign the treatment plan until December 13, 2011. Per review of the record of services provided, the client was present in treatment during this time period. The facility failed to document the development of an individual treatment plan with the client.
The facility director and clinical supervisor were interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
Clinical Supervisor shall review the policy and procedure for individual treatment plan development with the clinical staff, including the need for client signature to indicate the treatment plan was reviewed with the client.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation and policy through weekly clinical and chart supervision. |
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
Based on a review of client records, the facility failed to document a treatment plan update that included an assessment of the client's progress in relationship to the stated treatment plan goals in three of five outpatient client records.
The findings include:
Ten outpatient client records were reviewed on February 22, 2012. Five client records were reviewed for treatment plan updates. The facility failed to document treatment plan updates that included an assessment of the client's progress in relationship to the stated treatment plan goals in client records # 2, 3 and 4.
Client # 2 was admitted into treatment on November 15, 2011. The individual treatment plan was completed on December 9, 2011. A treatment plan update was completed on December 29, 2011. The treatment plan update did not include an assessment of the client's progress in relationship to the stated treatment plan goals.
Client # 3 was admitted into treatment on October 24, 2011. The individual treatment plan was completed on November 22, 2011. A treatment plan update was completed on January 23, 2012. The treatment plan update did not include an assessment of the client's progress in relationship to the stated treatment plan goals.
Client # 4 was admitted into treatment on October 18, 2011. The individual treatment plan was completed on October 24, 2011. A treatment plan update was completed on December 20, 2011. The treatment plan update did not include an assessment of the client's progress in relationship to the stated treatment plan goals.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Clinical Supervisor will review the requirement to accurately reflect an assessment of the client's progress in relationship to established goals on a treatment plan update with clinical staff.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation, as per facility policy, in three of five outpatient client records.
The findings include:
Ten outpatient client records were reviewed on February 22, 2012. Five client records were reviewed for case consultations. Per facility policy, a case consultation will be conducted every 90 days. A consultation should include the primary counselor and at least one other clinician. The facility failed to document a case consultation every 90 days in client records # 1, 3 and 5.
Client # 1 was admitted into treatment on November 9, 2011. A case consultation was due to be completed no later than February 9, 2012. A case consultation was not completed until February 16, 2012.
Client # 3 was admitted into treatment on October 24, 2011. A case consultation was due to be completed no later than January 24, 2012. A case consultation was not completed until February 6, 2012.
Client # 5 was admitted into treatment on November 1, 2011. A case consultation was due to be completed no later than February 1, 2012. A case consultation note was signed by the primary counselor on February 1, 2012. A second counselor signed the case consultation note on February 2, 2012. The narrative of the case consultation note does not indicate the date of the consultation or the names of the persons attending and their discipline. It is unknown if a case consultation actually occurred between these two clinicians.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Clinical Supervisor will review the requirement to complete a case consultation every 90 days and the appropriate documentation and signatures of the case consultation reflecting specifically when the consultation occurred with the clinical staff.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of the facility's policy and procedure manual and client records, the facility failed to document follow-up information in two of five outpatient client records.
The findings include:
Ten outpatient client records were reviewed on February 22, 2012. Five client records were closed and required documentation of a follow-up attempt. Per agency policy, a follow-up will be conducted within six months of discharge. The facility failed to conduct a follow-up within six months of discharge in client records # 6 and 7.
Client # 6 was admitted into treatment on April 26, 2011 and discharged on August 1, 2011. A follow-up attempt was due to be completed no later than February 1, 2012. The facility failed to provide documentation of a follow-up attempt as of February 22, 2012.
Client # 7 was admitted into treatment on May 31, 2011 and discharged on August 2, 2011. A follow-up attempt was due to be completed no later than February 2, 2012. The facility failed to provide documentation of a follow-up attempt as of February 22, 2012.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Follow-Up letters for Clients # 6 and 7 have been sent.
Clinical Supervisor will review with clerk-typist the requirement to send the Follow-Up letter within 6 months from discharge.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through monthly discharge reviews. |