INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 5, 2008 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 and a plan of correction is due on April 7, 2008.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on review of the policy and procedure manual during the inspection of February 4-7, 2008, the facility did not include time frames for the completion of the components of the staff development program.
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Plan of Correction
Project Director shall rewrite the policy and procedure regarding Staff Development Program to include time frames for the completion of the components.
It shall be the responsibility of the Project Director to insure all policy and procedures are accurate and comply with regulations through annual reviews of all policy and procedures.
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709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on review of client records during the licensing inspection March 5, 2008, the facility failed to document a complete psychosocial evaluation. Negative factors was missing and counselor conclusions/impression was incomplete in client record #7, one out of one client record reviewed.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff in proper documentation of the psychosocial evaluation including negative factors and counselor conclusion/impressions.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart review and clinical supervision. |
709.82(a)(1) LICENSURE Treatment and rehabilitation services
709.82. 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:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on review of the client record during the licensing inspection of March 5, 2008, the facility failed to document treatment and rehabilitation plans that included short and long term goals that were realistic and stated with measurable criteria. Action plan steps on the treatment plan failed to address how and what the client is to do relative to the issues identified on the client treatment plan. This was evident in one out of one client records reviewed, specifically client record #7.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff on treatment and rehabilitation plans, specifically action steps that address how and what the client is to do relative to the issues identified on the client treatment plans.
It shall also be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision
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709.83(a)(9) LICENSURE Client records
709.83. 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:
(9) Progress notes.
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Observations
Based on review of client records during the licensing inspection on March 5, 2008, the group progress notes failed to include a complete data, and assessment of the group session and failed to demonstrate consistency with the treatment rehabilitation plan objectives. Group notes were incomplete in one out of one client record reviewed, specifically client record # 7.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff regarding required elements of a group note including complete data, assessment of the group process, consistency with treatment plan objectives, and all other required elements of a progress/group note.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision.
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on review of the policy and procedure manual an staff interviews during the licensing inspection of February 8, 2008, the project director failed to remove all of the contradictory policy, procedure and time frames when the manual was updated . The manual contained conflicting policy and procedure for treatment plan updates, medical histories and the psychosocial history/evaluation. One policy statement claims that physical examinations will not be done, while another requires the completion of the physical examination form. Staff indicate that the intake and assessment process must be completed within 15 days, but time frames were not provided in the policy and procedure manual.
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Plan of Correction
Project Director shall again review and remove all contradictory policies and procedures and contradictory language throughout the manuals. Project Director will again replace with concise and accurate policies and procedures.
It shall be the responsibility of the Project Director to insure ongoing compliance with this regulation through annual reviews of the policy and procedure manuals.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of the policy and procedure manual and administrative material during the licensing inspection of February 4-7,2008, the annual audit was in drat form for the financial year ending June 30, 2007 and could not be considered complete. The final audit has yet to be completed due to the project not getting all the fiscal information needed to complete the report back until January 2008.
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Plan of Correction
In the future, SPHS Behavioral Health will provide documentation that we meet eligible criteria under the Circular OMB133 or "Single Audit Act" and will be eligible for an extension on the complete final audit.
It shall be the responsibility of the Project Director to insure ongoing compliance with this regulation and insure this audit is completed within the time frames of the Circular OMB133 or "Single Audit Act".
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on review of client records during the licensing inspection of March 5, 2008, the facility failed to document a complete personal history. The personal histories were incomplete in the following areas: family (client records # 2, 3, 5 and 6), educational (client record # 2), recreational (client records # 5 and 6) and sexual (client record # 2, 3, 5 and 6). In addition, the intake documents in client record # 3 had no date of completion, making it impossible to determine when the documents were completed and if the intake material was completed within the project's time frames.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff regarding the documentation of complete personal histories, specifically in the areas of family, histories, employment, educational, recreational, and sexual histories. In addition, it shall be the responsibility of the Clinical Supervisor to review and train all staff on proper clinical documentation of dates to insure the psychosocial evaluation is completed within the appropriate time frames.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart review and clinical supervision.
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709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on review of client records during the licensing inspection of March 5, 2008, the facility failed to document treatment and rehabilitation plans that included short and long term goals that were realistic and stated measurable criteria. Action plan steps on the treatment plans failed to address how and what the client is to do relative to the issues identified on the client treatment plans. This was evident in four out of six client records reviewed, specifically # 1, 3, 5 and 6.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff on treatment and rehabilitation plans, specifically action steps that address how and what the client is to do relative to the issues identified on the client treatment plans.
It shall also be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision.
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709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on review of client records during the licensing inspection on March 5, 2008, the group progress notes failed to include a complete data, and assessment of the group session and failed to demonstrate consistency with the treatment rehabilitation plan objectives. Group notes were incomplete in six out of six client records reviewed, specifically client records, # 1, 2, 3, 4, 5 and 6.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff regarding required elements of a group note including complete data, assessment of the group process, consistency with treatment plan objectives, and all other required elements of a progress/group note.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on review of client records during the licensing inspection of March 5, 2008, the facility failed to document when the discharge summary was completed. A completion date was not included on the discharge summary, making it impossible to determine if the material was completed in a timely manner. Refer to client records # 5 and 7. In addition one discharge summary was not documented in client record # 6.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review and train all clinical staff regarding the documentation of the date a discharge summary is completed.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart reviews and clinical supervision.
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