This report is a result of an on-site licensure renewal inspection conducted on January 29, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Care Center dba SPHS Care Center, 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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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 TB/STD and other health related topics within the first year of employment in one record.
Staff #6 was hired as a counselor on December 26, 2023, and still employed at time of inspection. Staff #6 was due to have the communicable disease trainings no later than December 26, 2024. There was no documentation provided of the completion of the TB/STD training as of the date of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical supervisor facilitated group supervision on 2/6/25 and reviewed the SPHS internal policy and DDAP training policy regarding required staff trainings and related timelines. This included specific review that all 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 within their first 1-2 years with the agency, based on their role. The Supervisory team reviewed necessary training certificates for all staff via a tracking document following this meeting. It was noted that the staff member identified during the annual review did complete the needed training on 2/4/25 and 2/5/25 and a certificate was provided to supervisors on 2/6/25. No later than 2/28/25, the Clinical Supervisor will provide letters to staff and HR to outline any required trainings that remain incomplete. All staff will be required to provide updates regarding their scheduled trainings at their individual supervisions. Upon completion of any training staff will provide the certificate of attendance and related training review to a member of the Supervisory team. At this time, the date will be logged in the tracking document and the certificate and evaluation will be filed in the staff training binder. The updated training tracking document will be sent to the Clinical Director periodically for review. A mock audit will occur in approximately 6 months. This audit will be conducted by another member of the Management Team and will confirm that trainings have been completed via review of the staff training binder as well as the tracking document. |
Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in three of seven records.
Client #2 was admitted to the outpatient level of care on June 26, 2024, and discharged on December 10, 2024. A treatment plan was completed on June 26, 2024, and an update was due no later than August 26, 2024; however, it was completed on August 27, 2024.
Client #3 was admitted to the outpatient level of care on May 21, 2024, and discharged on October 8, 2024. A treatment plan update was completed on July 30, 2024, and the next update was due no later than September 30, 2024; however, it was completed on October 8, 2024.
Client #7 was admitted to the outpatient level of care on September 6, 2024, and was still active at the time of the inspection. A treatment plan was completed on October 23, 2024, and an update was due no later than December 23, 2024; however, it was completed on January 8, 2025.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the January 10, 2024 licensing inspection.
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Plan of Correction
Clinical Supervisor facilitated group supervision on 2/6/25 and reviewed the SPHS internal policy and DDAP Regulatory Standards for Treatment Plan updates and related time frames ensuring that treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. Of particular focus was a re-training on the importance of all updates being completed no later 60 days after completion regardless of the client's actual service delivery or presence in the facility leading up to this date. A group supervision form was completed and signed by all clinical staff present acknowledging they have been re-trained on this requirement. Clinical staff that were not present will review the information with a member of the Supervisory team at their next scheduled individual supervision and will sign the individual supervision log confirming re-training of this requirement. A copy of both the group supervision form and each individual supervision log will be sent to the Clinical Director to confirm that the training occurred no later than 2/28/25. To ensure the completion of updated treatment plans, a member of the Supervisory team will review upcoming treatment plan deadlines each week and will email each staff a list of needed updates. This will occur in addition to notifications that are sent in the electronic health record and individualized tracking documents that staff utilize for caseload management. Any treatment plans that remain incomplete by day 59 will be completed by a member of the Supervisory team to ensure compliance. Related performance improvement plans and/or actions plans will be completed as appropriate with staff who demonstrate a failure complete these items. Random chart reviews will be documented in the client record either electronically via the Chart Review service in the client's electronic health record or, if completed on paper, via scanning into the client's record. A mock audit will occur in approximately 6 months and will be conducted by another member of the Management Team to confirm that treatment plan updates are occurring as required throughout an individual's treatment. |