INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 25 - 26, 2017 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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709.28 (c) 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.
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Observations
The facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in two of thirteen client records reviewed during the annual licensing inspection conducted on January 25 - 26, 2017. In addition, the project exceeded the limitations imposed at 4 Pa. Code 255.5 (b) in three of thirteen client records.
A consent to release information was not documented for the insurance company and the facility disclosed by fax the client's name and diagnosis when requesting prior authorization for medications in the following client records.
Client # 1 was admitted into treatment on May 17, 2016 and discharged on July 29, 2016. The disclosure occurred on June 7, 2016.
Client # 4 was admitted into treatment on July 14, 2016. The disclosure occurred on January 5, 2017.
The following client records were not compliant with 4 Pa. Code 255.5 (b), as the consents to the probation office indicated urine results, results of assessment and treatment goals would be released.
Client # 2 was admitted into treatment on April 29, 2016. The consent was signed by the client on April 29, 2016.
Client # 8 was admitted into treatment on October 20, 2016. The consent was signed by the client on October 20, 2016.
The following client record was not compliant with 4 Pa. Code 255.5 (b), as the facility released evaluation recommendations and the client's diagnosis in a letter to the employer.
Client # 9 was admitted into treatment on February 11, 2016 and discharged on May 25, 2016. The disclosure occurred on February 17, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will obtain appropriate Consents to Release Information for client numbers 1, 2, 4, and 8 where obtaining the consents are possible and remain relevant. The Clinical Supervisors will develop and provide a training update of the accurate and appropriate completion of consents to release information by Feb 28, 2017. Information to be covered will include appropriate type of release, the appropriate release for funding sources, appropriate choice of information to be released; and limitations of 4 Pa. code subsection 255.5, at a minimum. This will be completed by Feb 28, 107. Clinical Supervisor will continue to review and monitor consents and releases through internal chart reviews and supervision. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility's physician failed to document the basis for determination of current dependency and evidence of a one year history of addiction in two of four patient records reviewed during the annual licensing inspection conducted on January 25 - 26, 2017.
Patient # 3 was admitted into treatment on August 2, 2016. The patient was prescribed Suboxone on November 16, 2016.
Patient # 4 was admitted into treatment on July 14, 2016. The patient was prescribed Suboxone on November 9, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Supervisor will review with physician the standards for documenting the basis for determination of current dependency and evidence of a one year history of addiction. This will be completed by 2/28/17. The program supervisor will conduct random chart audits to ensure the reoccurrence of errors. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
The facility failed to complete an initial drug-screening urinalysis and a random monthly urinalysis in two of four patient records reviewed during the annual licensing inspection conducted on January 25 - 26, 2017.
Patient # 2 was admitted into treatment on April 29, 2016. The patient was prescribed Suboxone on June 1, 2016. A random monthly urinalysis was not documented for the following months: July, August, September and October 2016.
Patient # 4 was admitted into treatment on July 14, 2016. The patient was prescribed Suboxone on November 9, 2016. An initial drug-screening urinalysis was not documented. A random monthly urinalysis was not documented for the month of December 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program supervisor will review with all staff the policy and procedure for MAT individuals. The supervisor will tress the importance of initial drug screening urinalysis and random monthly urinalysis must be completed and sent to a lab for MAT individuals receiving Suboxone. This will be completed by 2/15/17 |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
The facility exceeded the maximum licensed capacity for the outpatient activity based on the Staffing Requirements Facility Summary Report form reviewed during the annual licensing inspection conducted on January 25 - 26, 2017.
The facility is licensed for a maximum capacity of 300 outpatient clients. The Staffing form documented a current census of 318 outpatient clients.
The findings were confirmed by the facility director during the licensing process.
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Plan of Correction
The supervisor and clinician's will evaluate current caseloads and determine cases to be discharged by 3/15/17. The clinical director will be advised of current capacity at monthly supervisor meetings to manage capacity and not go over caseload capacity. The Clinical supervisor will request a capacity increase to help prevent future occurrence. This will occur by 3/15/17. |