INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 20, 2013 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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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.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of TB/STD training in one of one personnel records.
The findings include:
Six personnel records were reviewed on February 13, 2013. One personnel record was reviewed for documentation of TB/STD training. The facility failed to document TB/STD training in personnel record # 6.
Employee # 6 was hired for the position of counselor on August 1, 2011. TB/STD training was due to be completed no later than August 1, 2012. There was no documentation of TB/STD training in personnel record # 6, as of February 13, 2013.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Employee #6 will be scheduled immediately for the next available TB/STD training.
It shall be the responsibility of the clinical supervisor to insure ongoing compliance with this regulation through routine reviews of trainings plans and employee training files. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director and facility director in two of two personnel records.
The findings include:
Six personnel records were reviewed on February 13, 2013. Two personnel records pertained to the project director and facility director and required documentation of 12 clock hours of annual training. The training year reviewed was from July 1, 2011 through June 30, 2012. The facility failed to document 12 clock hours of annual training for the 2011/2012 training year in personnel records # 1 and 2.
Employee # 1 was hired as the project director on July 1, 1978. Personnel record # 1 did not include documentation of any training hours for the 2011/2012 training year, as of February 13, 2013.
Employee # 2 became the facility director on July 16, 2004. Personnel record # 2 only included documentation of 6 training hours for the 2011/2012 training year, as of February 13, 2013.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Project Director has received 7 hours of training and Facility Director has obtained 12 hours of required training this calendar year.
Project Director will obtain the remaining hours to meet the 12 hours of required training. Project and Facility Director will insure ongoing compliance with this regulation.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one personnel records.
The findings include:
Six personnel records were reviewed on February 13, 2013. Three personnel records pertained to counselors. One counselor required the completion of 25 clock hours of annual training. Two counselors were new hires and were not yet due for training hours. The training year reviewed was from July 1, 2011 through June 30, 2012. The facility failed to document 25 clock hours of annual training for the 2011/2012 training year in personnel record # 4.
Employee # 4 is a counselor and was hired on March 21, 2007. Personnel record # 4 only included documentation of 18 clock hours of annual training for the 2011/2012 training year, as of February 13, 2013.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Counselors will be scheduled for the required 25 hours of training through the end of this training year.
It shall be the responsibility of the clinical supervisor to insure ongoing compliance with this regulation through routine reviews of training records for counselors.
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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
Based on a review of patient records, the facility's physician failed to document in the patient's record the basis for the determination of current dependency and evidence of a one year history of addiction in one of one patient records.
The findings include:
Nine client records were reviewed on February 20, 2013. One patient was prescribed Suboxone. This patient record was reviewed for documentation that the physician made a face-to-face determination of whether the individual was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for this determination. The physician failed to document in the patient's record the basis for determination of current dependency and evidence of a one year history of addiction in patient record # 5.
Patient # 5 was admitted into treatment on September 10, 2012. The physician conducted a face-to-face visit with patient # 5 on September 20, 2012. The physician prescribed 8 mg/2 mg Suboxone daily. The physician failed to document whether patient # 5 was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for the determination.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and did not dispute the findings.
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Plan of Correction
Facility physician will document the basis for the determination of current dependency and evidence of one year history of addiction.
It shall be the responsibility of the facility physicians to document appropriately. It shall also be the responsibility of the clinical supervisor to insure ongoing compliance with this regulation through weekly chart reviews.
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