INITIAL COMMENTS
|
This report is a result of an onsite follow-up inspection regarding the plans of correction for the February 22, 2012 licensure renewal inspection. The follow-up inspection was conducted on September 25, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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
|
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.
|
Observations
Based on an interview with the clinical supervisor, the facility failed to provide documentation of TB/STD training in one of one personnel training records.
The findings include:
The clinical supervisor was interviewed during a plan of correction follow-up inspection conducted on September 25, 2012. Employee # 6 was required to have documentation of TB/STD training. Based on the facility's plan of correction from the February 22, 2012 licensing inspection, employee # 6 was due to complete this training by May 18, 2012. The facility failed to provide documentation of TB/STD training for employee # 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 as of September 25, 2012.
The clinical supervisor confirmed the findings.
|
Plan of Correction
Employee #6 will be scheduled to attend the required TB/STD training at the next available training offered. Employee #6 had been on maternity leave and the training she was scheduled for was cancelled by provider.
It shall be the responsibility of the Clinical Supervisor to insure Employee #6 attends TB/STD Training. |
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.
|
Observations
Based on a review of client records, the facility failed to document treatment and rehabilitation plan updates at least every 60 days in three of four client records.
The findings include:
Ten client records were reviewed on September 25, 2012. Four client records were reviewed for treatment plan updates. Per facility policy, treatment plan updates will be completed every 60 days. The facility failed to document treatment plan updates at least every 60 days in client records # 2, 3 and 5.
Client # 2 was admitted into treatment on May 1, 2012. The treatment plan was completed on May 23, 2012. A treatment plan update was due to be completed no later than July 23, 2012 but was not documented until August 2, 2012.
Client # 3 was admitted into treatment on June 11, 2012. The treatment plan was due to be completed no later than July 11, 2012. A treatment plan update was due to be completed no later than September 11, 2012 but was not documented until September 24, 2012.
Client # 5 was admitted into treatment on May 15, 2012. The treatment plan was completed on June 15, 2012. A treatment plan update was due to be completed no later than August 15, 2012. Two treatment plan updates were not documented until September 7 and September 20, 2012.
The clinical supervisor was interviewed on September 25, 2012 and confirmed the findings.
|
Plan of Correction
Clinical Supervisor will review the requirement to update treatment plans within 60 days of last treatment plan.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance of this regulation through weekly clinical supervision and chart reviews. |