INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 25, 2023 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:
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Plan of Correction
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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 outpatient client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in three out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 90 days following admission.
Client #2 was admitted on July 15, 2022 and was still active at the time of the inspection. A case consultation was completed on July 18, 2022 and the next one was due no later than October 18, 2022; however, the next one was completed November 30, 2022.
Client #3 was admitted on May 17, 2022 and was still active at the time of the inspection. A case consultation was completed on September 15, 2022 and the next one was due no later than December 15, 2022; however, the next one was completed January 5, 2023.
Client #7 was admitted on March 8, 2022 and was discharged on July 18, 2022. A case consultation was completed on March 8, 2022 and the next one was due no later than June 8, 2022; however, the next one was completed July 18, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Weekly group staffing/supervision on February 22nd, 2023 from 3:00pm to 4:00pm will be facilitated by the Clinical Supervisor and will include reviewing the SPHS internal policy and DDAP Regulatory Standards for Case Consultations ensuring that all Clients have a Case Consultation documented in their EHR a minimum of every 90 days. A group supervision form will be completed and signed by all clinical staff participants acknowledging they have been re-trained in the documentation of Case Consultations. A copy of this document will be sent to the Clinical Director for review and confirmation that the re-training occurred. Latrobe employees that are not present, based on their in office availability will review the information with the Clinical Supervisor or Team Leader at their next scheduled individual supervision and be required to sign the individual supervision log confirming re-training of the Case Consultation requirement/policy. A copy of each supervision log will be sent to the Clinical Director to confirm that the training occurred. During individual supervisions, Case Consultations will be documented by either the clinician and/or the Supervisor/Team Leader at the time of the Supervision. Random Chart Reviews will be conducted throughout the year by members of the Supervisory Team to ensure compliance. These Chart Reviews will be documented in the client record through either the Chart Review service or scanned into the client chart by the Clinical Supervisor/Team Leader or Delegate. A mock audit will occur in approximately 6 months. This audit will be conducted by another member of the Management Team and will confirm that Case Consultations are being entered into the EHR. |
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 outpatient client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of three discharged records reviewed.
Client #6 was admitted on April 27, 2022 and was discharged on July 11, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Weekly group staffing/supervision on February 22nd, 2023 from 3:00pm to 4:00pm will be facilitated by the Clinical Supervisor and will include reviewing the SPHS internal policy and DDAP Regulatory Standards for 6-month Follow-up (from Discharge) letters ensuring that all Discharged Clients have a a follow-up letter sent 6 months from discharge and that this letter is documented in their EHR . A group supervision form will be completed and signed by all clinical staff participants acknowledging they have been re-trained in the documentation of the 6-month Follow-up Letters. A copy of this document will be sent to the Clinical Director for review and confirmation that the re-training occurred. Latrobe employees that are not present, based on their in office availability will review the information with the Clinical Supervisor or Team Leader at their next scheduled individual supervision and be required to sign the individual supervision log confirming re-training of the 6-month Follow-up Letter requirement/policy. A copy of each supervision log will be sent to the Clinical Director to confirm that the training occurred. The 6-month Follow-Up Letter has been added to the Discharge Form group in the Credible Operating System. Random Chart Reviews will be conducted throughout the year by members of the Supervisory Team to ensure compliance. These Chart Reviews will be documented in the client record through either the Chart Review service or scanned into the client chart by the Clinical Supervisor/Team Leader or Delegate. A mock audit will occur in approximately 6 months. This audit will be conducted by another member of the Management Team and will confirm that 6-month Follow-Up Letters are being sent out and entered into the EHR. |