INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8, 2014 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the review of the facility's fire drill records, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
The facility's fire drill records for December 2013 to June 2014 were requested for review on July 8, 2014. There were no fire drills documented from December 2013 to June 2014.
The Facility Director and Clinical Supervisor were interviewed on July 8, 2014 and confirmed the findings.
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Plan of Correction
The Clinical Supervisor will be retrained regarding fire safety regulations by the Facility Director. This was completed on 7/9/14. July's fire drill will occurr on 7/30/14. The Clinical Supervisor will conduct and document fire drills monthly. |
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 the review of client records, the facility failed to document informed and voluntary consent to release client information forms, to include the purpose and/or expiration date, in four of seven client records reviewed.
The findings include:
Seven client records were reviewed on July 8, 2014 for the completion of informed and voluntary consent to release client information forms. The facility failed to document informed and voluntary consent to release information forms, to include the purpose and/or expiration date, in client records # 1, 3, 5 and 7.
Client # 1 was admitted on January 8, 2014. A consent to release client information form for the client's funding source, signed by the client on June 28, 2014, did not include the purpose or the expiration date of the consent form.
Client # 3 was admitted on February 19, 2014. A consent to release client information form for the probation office, signed by the client on February 14, 2014, did not include the expiration date of the consent form.
Client # 5 was admitted on March 12, 2014. A consent to release client information form for another treatment provider, signed by the client on June 11, 2014, did not include the expiration date of the consent form.
Client # 7 was admitted on June 4, 2014. The record included documentation of an admission letter that was sent to the probation office on June 5, 2014. There was no documentation provided to verify that the client had signed a consent form to release the information.
The Facility Director and Clinical Supervisor were interviewed on July 8, 2014 and confirmed the findings.
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Plan of Correction
The facility will obtain appropriate Consents to Release Information for all new clients and current clients. New release forms will be completed on current clients as soon as they are seen in the office. The Clinical Supervisor will provide a thorough training update on the accurate and appropriate completion of consents to release information on July 30th, 2014. 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. Clinical Supervisor will continue to review and monitor consents and releases through internal chart reviews and supervision. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of client records, the facility failed to document that the client was informed of their rights in six of seven client records.
The findings include:
Seven client records were reviewed on July 8, 2014. Six client records were reviewed for documentation that the client was informed of their rights. There was no documentation in client records # 1, 2, 3, 4, 5 and 6 that the client was informed of their rights.
The Facility Director and Clinical Supervisor were interviewed on July 8, 2014 and confirmed the findings.
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Plan of Correction
The Facility will document the receipt of Client Bill of Rights for all new and current clients this will occurr immediately. The Client Bill of Rights will be given to current clients as soon as they are seen in the office and staff will document that the client was given this information. The Clinical Supervisor will provide training and supervision to all staff regarding procedures for intake and review the importance of informing clients of their Bill of Rights and the importance of documenting the receipt of the Bill of Rights. This will be completed on July 30, 2014. The Clinical Supervisor will continue to review and monitor intakes. This will be an ongoing process. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on the review of client records, the facility failed to document that the client was oriented as part of the intake procedure in six of seven client records.
The findings include:
Seven client records were reviewed on July 8, 2014 for documentation that the client was oriented to the project. The facility failed to document that the client was oriented to the project in client records # 1, 2, 3, 4, 5 and 6.
The Facility Director and Clinical Supervisor were interviewed on July 8, 2014 and confirmed the findings.
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Plan of Correction
The Facility will document the receipt of orientation on all new and current clients and this will occurr immediately. Current clients will be given a new orientation packet and clinical staff will orient the client to the project as soon as they are seen in the office. The Clinical Supervisor will provide training and supervision to all staff regarding procedures for intake and review the importance of orienting clients to the project and obtaining documentation of clients receiving orientation to the project. This will be completed on July 30th, 2014. The Clinical Supervisor will continue to review and monitor intakes. This will be an ongoing process.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on the review of client records, the facility failed to document a consent to treatment in six of seven client records reviewed.
The findings include:
Seven client records were reviewed for documentation of consent to treatment on July 8, 2014. The facility failed to document a consent to treatment in client records # 1, 2, 3, 4, 5 and 6.
The Facility Director and Clinical Supervisor were interviewed on July 8, 2014 and confirmed the findings.
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Plan of Correction
The Facility will obtain a consent for treatment for all new and current clients this will occurr immediately. Clinical staff will obtain consent for treatment as soon as current clients are seen in the office. The Clinical Supervisor will provide training and supervision to all staff regarding procedures for intake and review the importance of obtaining consent for treatment. This will occurr on July 30th, 2014. The Clinical Supervisor will continue to review and monitor intakes. This will be an ongoing process. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation as part of the intake procedure in five of five client records reviewed.
The findings include:
Seven client records were reviewed on July 8, 2014. Five client records were reviewed for the completion of a psychosocial evaluation. A psychosocial evaluation was not documented in client records # 1, 2, 3, 4 and 5.
Client # 1 was admitted on January 8, 2014. There was no documentation of a psychosocial evaluation as of July 8, 2014.
Client # 2 was admitted on December 30, 2013. There was no documentation of a psychosocial evaluation as of July 8, 2014.
Client # 3 was admitted on February 19, 2014. There was no documentation of a psychosocial evaluation as of July 8, 2014.
Client # 4 was admitted on March 19, 2014. There was no documentation of a psychosocial evaluation as of July 8, 2014.
Client # 5 was admitted on March 12, 2014. There was no documentation of a psychosocial evaluation as of July 8, 2014.
The Facility Director and Clinical Supervisor were interviewed on July 8, 2014 and confirmed the findings.
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Plan of Correction
A psychosocial evaluation was completed for all clients on 7/22/14. Clinical staff will complete a psychosocial evalaution on all new admissions within 15 days of admission. The Clinical Supervisor will review the requirement to complete a psychosocial evaluation and regulatory standards with an emphasis on due dates and time lines. A training will be held for staff as part of their staff meetings and clinical support to provide direct instruction on effectively documenting psychosocial assessment within the specific due dates. This was completed on 7/22/14. Clinical Supervisor will continue to review and psychosocial evaluations. |
709.93(a) 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:
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Observations
Based on the review of client records, the facility failed to document a complete client record that included case consultation notes in five of five client records.
The findings include:
Seven client records were reviewed on July 8, 2014. Five client records were reviewed for the completion of case consultation notes. The facility failed to document case consultation notes in client records # 1, 2, 3, 4 and 5.
Client # 1 was admitted on January 8, 2014. The record did not include documentation of a case consultation note as of July 8, 2014.
Client # 2 was admitted on December 30, 2013. The record did not include documentation of a case consultation note as of July 8, 2014.
Client # 3 was admitted on February 19, 2014. The record did not include documentation of a case consultation note as of July 8, 2014.
Client # 4 was admitted on March 19, 2014. The record did not include documentation of a case consultation note as of July 8, 2014.
Client # 5 was admitted on March 12, 2014. The record did not include documentation of a case consultation note as of July 8, 2014.
The Facility Director and Clinical Supervisor were interviewed on July 8, 2014 and confirmed the findings.
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Plan of Correction
On July 22nd, 2014 a mandatory staff meeting will was held with all staff to review case consultation timelines and regulations. Each staff member will be provided with a copy of our agency's policy and regulations in regard to case consultation timelines. All case consults were completed for all active clients on July 22nd, 2014. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor.
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