INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 16, 2016 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 ensure staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in one of three personnel records.
The findings include:
Seven personnel records were reviewed on February 16, 2016. Three personnel records were reviewed for documentation of HIV/AIDS and tuberculosis, sexually transmitted diseases (TB/STD) and other health related topics training. The facility failed to ensure employee # 7 received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training.
Employee # 7 was hired as a counselor on December 16, 2014. HIV/AIDS and TB/STD training was due to be completed no later than December 16, 2015. There was no documentation of HIV/AIDS and TB/STD training in personnel record # 7, as of February 16, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will review with supervisor the policy and procedure of ensuring that all staff require the mandatory trainings to meet state regulations. Employee number 7 will be scheduled to attend the 6 hours of HIV/AIDS and 4 hours of TB/STD training. This will occur no later than 6/30/16. The Clinical supervisor will ensure that this staff and any future staff attend mandatory trainings in the appropriate time frames. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observation during a physical plant inspection conducted on February 16, 2016, the facility failed to ensure that exits from the nonresidential facility were unobstructed and operable at all times.
The findings include:
A physical plant inspection was conducted on February 16, 2016 at approximately 8:50 AM. The emergency exit door at the rear of building was observed to have a double keyed deadbolt lock. This lock would prevent the emergency exit door from being operable at all times. The facility failed to ensure that exits from the nonresidential facility were unobstructed and operable at all times.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will be in contact with landlord about recent modification he had made to the doors. The doors will be modified or replaced to meet regulation standards. This will occur no later than 4/1/16. The clinical supervisor will be responsible for monthly inspections of exits to ensure they are unobstructed and meet regulatory standards. |
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, the facility failed to obtain a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in two of ten client records.
The findings include:
Ten client records were reviewed on February 16, 2016. Ten client records were required to include documentation of written, informed and voluntary consents from the client. The facility failed to obtain a written, informed and voluntary consent from the client prior to disclosing information contained in the client record in records # 1 and 5.
Client # 1 was admitted into treatment on August 17, 2015. The client's name, diagnosis and request for prescription authorization was faxed to the insurance company on October 13, 2015. There was no documentation of a written consent to release information to this insurance company in client record # 1, as of February 16, 2016.
The client's name, diagnosis and prescription information and was faxed to the pharmacy on October 9, 2015. There was no documentation of a written consent to release information to this pharmacy or a Qualified Service Organization Agreement, as of February 16, 2016
Client # 5 was admitted into treatment on September 28, 2015 and discharged on February 1, 2016. The client's name, diagnosis and prescription information was faxed to the pharmacy on October 8, 2015. There was no documentation of a written consent to release information to this pharmacy or a Qualified Service Organization Agreement, as of February 16, 2016
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A mandatory staff meeting will be held with all staff to review regulations and guidelines when completing consents to release information. There will be a particular focus on making sure that releases are obtained for medical departments of insurance when obtaining authorization for medication and pharmacies. The clinical supervisor will hold the staff meeting. In addition, staff members who were responsible for charts 1 and 5 will obtain proper consents for those clients where it is appropriate. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor. This will occur no later than 3/31/16. |