INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 11, 2010 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 2, 2010.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, qualified service organization agreements and an interview with the facility director, the facility failed to document an informed and voluntary consent or a qualified service organization agreement when releasing urine samples to an outside agency for testing in fifteen out of fifteen client records.
The findings include:
Twenty-one client records were reviewed on March 11, 2010. Urine samples were sent to an outside agency in fifteen client records. Six client records included urine test results that were from a time frame outside of the current licensing inspection. Per regulation, the project shall obtain an informed and voluntary consent to release information from the client for the disclosure of information contained in the client record. Client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 14, 15, 19, 20 and 21 did not include a signed consent to release information nor was a qualified service organization agreement in place for the outside agency.
The facility director was interviewed on March 11, 2010 and confirmed the facility did not have a qualified service organization agreement with the agency that conducts urine testing. The facility director also confirmed that informed and voluntary consents had not been completed for clients who were participating in urine testing. The facility director reported a qualified service organization agreement will be obtained with the agencies that provide this testing for the facility.
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Plan of Correction
Project Director will obtain a Qualified Service Organization Agreement with all testing companies for the purpose of releasing drug testing samples and bloodwork. Clinical Supervisor will train staff on use of Consent to Release Information for appropriate laboratory testing companies until the QSOA is signed and received by Facility.
It shall be the responsibility of the Project and Facility Directors to obtain and maintain all QSOAs with testing companies for drug testing and bloodwork. It shall be the responsibility of the Project and Facility Director to insure ongoing compliance with this regulation through yearly reviews of all QSOAs.
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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 and an interview with the facility director and clinical supervisor, the facility failed to document the completion of treatment plan review and updates within sixty days, in four of ten client records.
The findings include:
Twenty-one client records were reviewed on March 11, 2010. Fifteen client records were from the outpatient program. Ten client records required treatment plan review and updates. Five client records were from a time frame outside of the current licensing inspection. Per regulation and the facility policy, treatment plan review and updates are required to be completed every sixty days. The facility failed to document treatment plan review and updates within sixty days, in client records # 1, 5, 6 and 7.
In client record # 1, the client was admitted on September 10, 2009. The comprehensive treatment plan was completed on October 23, 2009. The first treatment plan update was due no later than December 23, 2009. The facility failed to document the completion of the first treatment plan update. The second treatment plan update was due no later than February 23, 2010 and was completed on February 26, 2010.
In client record # 5, the client was admitted on September 3, 2009. The comprehensive treatment plan was completed on October 29, 2009. The first treatment plan update was due no later than December 29, 2009. The second treatment plan update was due no later than March 1, 2010. The facility failed to document the completion of both treatment plan updates.
In client record # 6, the client was admitted on November 13, 2009. The comprehensive treatment plan was completed on December 12, 2009. The first treatment plan update was due no later than February 12, 2010. The facility failed to document the completion of the first treatment plan update.
In client record # 7, the client was admitted on July 11, 2009. The comprehensive treatment plan was completed on August 11, 2009. The first treatment plan update was due no later than October 11, 2009. The second treatment plan update was due no later than December 11, 2009. The third treatment plan update was due no later than February 11, 2010. The facility failed to document the completion of any treatment plan updates.
The facility director and clinical supervisor were interviewed on March 11, 2010 and confirmed the treatment plan updates were not documented in the client records and should have been completed within the 60 day time frame. This is a repeat citation.
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Plan of Correction
Clinical Supervisor will review and re-retrain all clinical staff regarding the requirement to review and update treatment plans within sixty days.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart and clinical 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 and an interview with the facility director and clinical supervisor, the facility failed to document a case consultation in four of ten client records.
The findings include:
Twenty-one client records were reviewed on March 11, 2010. Fifteen client records were from the outpatient program. Ten client records required the completion of a case consultation. Four client records were from a time frame outside of the current licensing inspection. One client record did not require a case consultation. Per facility policy, case consultations will be completed every ninety days. The facility failed to document case consultations, in client records # 1, 5, 6 and 7.
In client record # 1, the client was admitted on September 10, 2009. The first case consultation was due no later than December 10, 2009; but was not completed until January 26, 2010.
In client record # 5, the client was admitted on September 3, 2009. Case consultations were due no later than December 3, 2009 and March 3, 2010. The facility failed to document the completion of any case consultations.
In client record # 6, the client was admitted on November 13, 2009. A case consultation was due no later than February 13, 2010. The facility failed to document the completion of a case consultation.
In client record # 7, the client was admitted on July 11, 2009. Case consultations were due no later than October 11, 2009 and January 11, 2010. The facility failed to document the completion of any case consultations.
The facility director and clinical supervisor were interviewed on March 11, 2010 and confirmed the case consultation in client record # 1 was late and the case consultations in client records # 5, 6 and 7 were not documented in the client records. This is a repeat citation.
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Plan of Correction
Clinical Supervisor will review and re-train all clinical staff regarding the requirement to conduct case consultations every 90 days.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation and policy through weekly chart and clinical supervision. |