INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 27 - 28, 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(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:
Fifteen 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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709.83(a)(11) LICENSURE Client records
709.83. 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in two of four partial hospitalization client records.
The findings include:
Four partial hospitalization records were reviewed on February 27, 2013. Four client records were closed and were due for a follow-up attempt. Per facility policy, a follow-up will be conducted within 6 months of the client's discharge. The facility failed to document a follow-up attempt in client records # 1 and 2.
Client # 1 was admitted into treatment on March 21, 2012 and discharged on April 17, 2012. A follow-up attempt was due to be completed no later than October 17, 2012. There was no documentation of follow-up information in client record # 1, as of February 27, 2013.
Client # 2 was admitted into treatment on March 19, 2012 and discharged on May 2, 2012. A follow-up attempt was due to be completed no later than November 2, 2012. There was no documentation of follow-up information in client record # 2, as of February 27, 2013.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Clients #1 and #2 have been sent a follow-up letter. The Clinical Supervisor will review with clerical staff the requirement to send a follow-up letter to clients within 6 months of discharge, per agency policy.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through quarterly review of discharges and follow-up letter reviews. |
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 a review of client records and the facility's orientation packet, the facility failed to demonstrate efforts toward informing clients of their rights in three of eleven client records.
The findings include:
Seventeen client records were reviewed on February 27 - 28, 2013. Eleven client records were reviewed for documentation that clients were informed of their rights. The facility's orientation packet includes a copy of client rights. Clients receive a copy of their rights during the orientation process and then sign off on the orientation checklist form. The facility failed to demonstrate efforts toward informing clients of their rights in client records # 6, 8 and 10.
Client # 6 was admitted into treatment on December 6, 2012. There was no documentation of a client orientation checklist in client record # 6. The facility failed to document that client # 6 was informed of their rights.
Client # 8 was admitted into treatment on September 28, 2012. There was no documentation of a client orientation checklist in client record # 8. The facility failed to document that client # 8 was informed of their rights.
Client # 10 was admitted into treatment on December 20, 2012. There was no documentation of a client orientation checklist in client record # 10. The facility failed to document that client # 10 was informed of their rights.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the process for informing clients of their rights and the findings.
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Plan of Correction
Client's #6, #8, and #10 have been given new orientation packets and documentation has been signed by the client indicating they have been informed of their client rights. The Clinical Supervisor will review with all clinical staff the requirement to review client rights and obtain documentation of such review.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of patient records, the facility failed to verify that the individual had reached 18 years of age prior to the administration of a narcotic agent in three of three patient records.
The findings include:
Seventeen client records were reviewed on February 27 - 28, 2013. Three records pertained to patients who were prescribed Suboxone and required verification that the individual had reached 18 years of age prior to the administration of the Suboxone. The facility failed to verify that the individual had reached 18 years of age prior to the administration of Suboxone in patient records # 6, 7 and 12.
Patient # 6 was admitted into treatment on December 6, 2012. Patient # 6 was prescribed 12 mg/3 mg Suboxone daily on January 16, 2013, prior to verifying that the individual had reached 18 years of age.
Patient # 7 was admitted into treatment on January 16, 2013. Patient # 7 was prescribed 12 mg/3 mg Suboxone daily on February 6, 2013, prior to verifying that the individual had reached 18 years of age.
Patient # 12 was admitted into treatment on January 18, 2013. Patient # 12 was prescribed 8 mg/2 mg Suboxone daily on January 31, 2013, prior to verifying that the individual had reached 18 years of age.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Clients #6, #7, and #12 have provided appropriate photo ID for age verification of 18 years old or older. The Clinical Supervisor will review with all clinical and medical staff the requirement to obtain appropriate photo ID on all clients prior to receiving a narcotic agent to verify they have reached the age of 18.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to verify the individual's identity, including the name, address and date of birth prior to the administration of a narcotic agent in three of three patient records.
The findings include:
Seventeen client records were reviewed on February 27 - 28, 2013. Three records pertained to patients who were prescribed Suboxone and required verification of the individual's identity, including name, address, date of birth and emergency contact prior to the administration of Suboxone. The facility failed to verify that the individual's identity, including the name, address and date of birth prior to the administration of Suboxone in patient records # 6, 7 and 12.
Patient # 6 was admitted into treatment on December 6, 2012. Patient # 6 was prescribed 12 mg/3 mg Suboxone daily on January 16, 2013, prior to verifying the individual's identity including the name, address and date of birth.
Patient # 7 was admitted into treatment on January 16, 2013. Patient # 7 was prescribed 12 mg/3 mg Suboxone daily on February 6, 2013, prior to verifying the individual's identity including the name, address and date of birth.
Patient # 12 was admitted into treatment on January 18, 2013. Patient # 12 was prescribed 8 mg/2 mg Suboxone daily on January 31, 2013, prior to verifying the individual's identity including the name, address and date of birth.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Clients #6, #7, and #12 have provided appropriate photo ID to verify the individual's identity including name, address, and date of birth. The Clinical Supervisor will review with the clinical and medical staff the requirement to obtain an appropriate photo ID to verify an individual's identity, including name, address, and date of birth.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
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:
Seventeen client records were reviewed on February 27 - 28, 2013. Three patients were 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 records # 6, 7 and 12.
Patient # 6 was admitted into treatment on December 6, 2012. The physician conducted a face-to-face visit with patient # 6 on January 16, 2013. The physician prescribed 12 mg/3 mg Suboxone daily on January 16, 2013. The physician failed to document whether patient # 6 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.
Patient # 7 was admitted into treatment on January 16, 2013. The physician conducted a face-to-face visit with patient # 7 on February 6, 2013. The physician prescribed 12 mg/3 mg Suboxone daily on February 6, 2013. The physician failed to document whether patient # 7 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.
Patient # 12 was admitted into treatment on January 18, 2013. The physician conducted a face-to-face visit with patient # 12 on January 31, 2013. The physician prescribed 8 mg/2 mg Suboxone daily on January 31, 2013. The physician failed to document whether patient # 12 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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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of patient records, the facility failed to maintain onsite a photograph of each patient which includes that patient's name and birth date in three of three patient records.
The findings include:
Seventeen client records were reviewed on February 27 - 28, 2013. Three records pertained to patients who were prescribed Suboxone and required documentation of a photograph including the patient's name and date of birth. The facility failed to maintain onsite a photograph of each patient which includes that patient's name and birth date in patient records # 6, 7 and 12.
Patient # 6 was admitted into treatment on December 6, 2012. Patient # 6 was prescribed 12 mg/3 mg Suboxone daily on January 16, 2013. The facility failed to maintain onsite a photograph of patient # 6 which includes their name and birth date.
Patient # 7 was admitted into treatment on January 16, 2013. Patient # 7 was prescribed 12 mg/3 mg Suboxone daily on February 6, 2013. The facility failed to maintain onsite a photograph of patient # 7 which includes their name and birth date.
Patient # 12 was admitted into treatment on January 18, 2013. Patient # 12 was prescribed 8 mg/2 mg Suboxone daily on January 31, 2013. The facility failed to maintain onsite a photograph of patient # 12 which includes their name and birth date.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Clients #6, #7, and #12 have provided appropriate Photo ID which includes the client name and date of birth. The clinical supervisor will review with all medical and clinical staff the requirement to obtain appropriate photo ID which included the client name and date of birth on all clients before receiving a narcotic agent.
It shall be the responsibility of the clinical supervisor to insure ongoing compliance with this regulantion through weekly clinical and chart supervision. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to complete an initial drug screening urinalysis for each prospective patient in one of three patient records.
The findings include:
Seventeen client records were reviewed on February 27 - 28, 2013. Three records pertained to patients who were prescribed Suboxone and required documentation of an initial drug screening urinalysis and a random monthly urinalysis. The facility failed to complete an initial drug screening urinalysis for each prospective patient in patient record # 6.
Patient # 6 was admitted into treatment on December 6, 2012. Patient # 6 was prescribed 12 mg/3 mg Suboxone daily on January 16, 2013, prior to the completion of an initial drug screening urinalysis. The only drug screening urinalysis was completed on February 14, 2013, after the Suboxone was prescribed to patient # 6. The facility failed to complete an initial dug screening urinalysis for patient # 6.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Clinical Supervisor will review with medical and clinical staff the requirement to obtain an initial urine drug screen for individuals prior to receiving a narcotic agent.
It shall be the responsibility of the clinical supervisor to insure ongoing compliance with this regulation through weekly chart and clinical supervision. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document the disclosure to the client of the criteria for admission and completion in three of nine outpatient client records.
The findings include:
Thirteen outpatient client records were reviewed on February 27 - 28, 2013. Nine client records were reviewed for documentation of the disclosure to the client of the criteria for admission, treatment, completion and discharge. The facility provides this information to the client during the orientation process and then the client signs off on the orientation checklist form. The facility failed to document the disclosure to the client of the criteria for admission and completion in client records # 6, 8 and 10.
Client # 6 was admitted into treatment on December 6, 2012. There was no documentation of a client orientation checklist form in client record # 6. The facility failed to document the disclosure to client # 6 of the criteria for admission and completion.
Client # 8 was admitted into treatment on September 28, 2012. There was no documentation of a client orientation checklist form in client record # 8. The facility failed to document the disclosure to client # 8 of the criteria for admission and completion.
Client # 10 was admitted into treatment on December 20, 2012. There was no documentation of a client orientation checklist form in client record # 10. The facility failed to document the disclosure to client # 10 of the criteria for admission and completion.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Clients #6, #8, and #10 have received and signed the Receipt of Orientation indicating they have been given the criteria for admission and completion of treatment. The Clinical Supervisor will review with the clinical staff the requirement to obtain documentation through the use of the Receipt of Orientation to document each client receiving services has been informed of criteria for admission and completion of treatment.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document the client's family medical history and history of illness and symptoms in 4 of 9 outpatient client records.
The findings include:
Thirteen outpatient client records were reviewed on February 27 - 28, 2013. Nine client records were reviewed for documentation of the client's personal medical history, family medical history and history of illness and symptoms. The facility failed to document the client's family medical history and history of illness and symptoms in client records # 6, 8, 10 and 11.
Client # 6 was admitted into treatment on December 6, 2012. A medical history was completed on December 4, 2012. There was no documentation of a family medical history or history of illness and symptoms in client record # 6, as of February 28, 2013.
Client # 8 was admitted into treatment on September 28, 2012. A medical history was completed on May 14, 2012. There was no documentation of a family medical history or history of illness and symptoms in client record # 8, as of February 28, 2013.
Client # 10 was admitted into treatment on December 20, 2012. A medical history was completed on December 13, 2012. There was no documentation of a family medical history or history of illness and symptoms in client record # 10, as of February 28, 2013.
Client # 11 was admitted into treatment on January 29, 2013. A medical history was completed on January 8, 2013. There was no documentation of a family medical history or history of illness and symptoms in client record # 11, as of February 28, 2013.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Clients #6, #8, #10, and # 11 have completed Medical Histories to document family medical history and history of illness and symptoms. The Clinical Supervisor will review with all clinical staff the requirement to obtain complete Medical Histories on all clients in treatment.
It shall be the responsibility of the Clinica Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
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 a review of client records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the client in three of nine outpatient client records.
The finding include:
Thirteen outpatient client records were reviewed on February 27 - 28, 2013. Nine client records were reviewed for psychosocial evaluations that included a clinical assessment of the client. The facility failed to document a psychosocial evaluation that included a clinical assessment of the client in client records # 5, 7 and 10.
Client # 5 was admitted into treatment on November 19, 2012. A psychosocial evaluation was completed on November 15, 2012. The psychosocial evaluation did not include a clinical assessment of the client's assets/strengths, support systems and the client's attitude toward and ability to participate in the treatment process and only included client reported historical information.
Client # 7 was admitted into treatment on January 16, 2013. A psychosocial evaluation was completed on January 7, 2013. The psychosocial evaluation did not include a clinical assessment of the client's assets/strengths and support systems and only included client reported historical information.
Client # 10 was admitted into treatment on December 20, 2012. A psychosocial evaluation was completed on December 17, 2012. The psychosocial evaluation did not include a clinical assessment of the client's assets/strengths, support systems, coping mechanisms and negative factors that might affect treatment and only included client reported historical information.
The clinical supervisor was interviewed throughout the licensing inspection and did not dispute the findings.
This is a repeat citation from the February 13 - 14, 2012 licensing inspection.
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Plan of Correction
The Clinical Supervisor will review the appropriate documentation and completion of Psychosocial Evaluations including a clinical assessment with all clinical staff.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
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, the facility failed to document a treatment plan update every 60 days that included an assessment of the client's progress in relationship to the stated treatment plan goals in three of four outpatient client records.
The findings include:
Thirteen outpatient client records were reviewed on February 27 - 28, 2013. Four client records were reviewed for treatment plan updates. Per facility policy, a treatment plan update will be completed every 60 days. The facility failed to document treatment plan updates that included an assessment of the client's progress in relationship to the stated treatment plan goals in client records # 6 and 8. The facility failed to document treatment plan updates every 60 days in client records # 5 and 8.
Client # 5 was admitted into treatment on November 19, 2012. The individual treatment plan was due to be completed on December 19, 2012. A treatment plan update was due to be completed no later than February 19, 2013. There was no documentation of any treatment plan updates in client record # 5, as of February 28, 2013.
Client # 6 was admitted into treatment on December 6, 2012. The individual treatment plan was completed on December 26, 2012. A treatment plan update was completed on February 25, 2013. The treatment plan update did not include an assessment of the client's progress in relationship to the stated treatment plan goals.
Client # 8 was admitted into treatment on September 28, 2012. The individual treatment plan was completed on October 25, 2012. A treatment plan update was completed on December 21, 2012. The treatment plan update did not include an assessment of the client's progress in relationship to the stated treatment plan goals. A second treatment update was due to be completed no later than February 21, 2013, but was not documented as of February 28, 2013.
The clinical supervisor was interviewed throughout the licensing inspection and did not dispute the findings.
This is a repeat citation from the February 13 - 14, 2012 licensing inspection.
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Plan of Correction
Client #5's treatment plan has been updated. Client #6's treatment plan goals have been updated to include an assessment of the client's progress in relationship to the stated goal. The Clinical Supervisor will review the appropriate time frames and completion of treatment plan updates with clinical staff.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical and chart supervision. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in two of five outpatient client records.
The findings include:
Thirteen outpatient client records were reviewed on February 27 - 28, 2013. Five client records were closed and were due for a follow-up attempt. Per facility policy, a follow-up will be conducted within 6 months of the client's discharge. The facility failed to document a follow-up attempt in client records # 13 and 15.
Client # 13 was admitted into treatment on May 4, 2012 and discharged on June 18, 2012. A follow-up attempt was due to be completed no later than December 18, 2012. There was no documentation of follow-up information in client record # 13, as of February 28, 2013.
Client # 15 was admitted into treatment on May 11, 2012 and discharged on June 20, 2012. A follow-up attempt was due to be completed no later than December 20, 2012. There was no documentation of follow-up information in client record # 15, as of February 28, 2013.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Client #13 and #15 have been sent follow-up letters. The Clinical Supervisor will review with the clerical staff the requirement to send follow-up letters within 6 months, per agency policy.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through quarterly discharge reviews. |