This report is a result of an on-site licensure renewal inspection conducted on January 17, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of 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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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 May 8, 2024, and discharged on July 22, 2024. A treatment plan was completed on May 8, 2024, and an update was due no later than July 8, 2024; however, it was completed on July 22, 2024.
Client #5 was admitted to the outpatient level of care on June 11, 2024, and was still active at the time of the inspection. A treatment plan was completed on June 11, 2024, and an update was due no later than August 11, 2024; however, it was completed on August 28, 2024.
Client #7 was admitted to the outpatient level of care on October 22, 2024, and was still active at the time of the inspection. A treatment plan update was completed on October 22, 2024, and the next update was due no later than December 22, 2024; however, it was completed on January 9, 2025.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the January 25, 2024 licensing inspection.
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Plan of Correction
During the staff meeting scheduled on 02/12/2025, the Clinical Supervisor will review with staff the importance of submitting timely Plans of Care within the 60-day time frame to ensure we are meeting DDAP regulatory standards along with the SPHS Policy for submission of services. This review will specifically focus on ensuring that staff complete care plans even when the client is not actively engaging in treatment services and/or preparing for discharge. At this time, the Clinical Supervisor will provide staff with client trackers that include the needed update dates for Plans of Care to ensure each clinician is tracking dates. Staff not in attendance at the 02/12/2025 meeting will review the timeliness of the Plan of Care submission and the client tracker no later than 02/26/2025.
Compliance with this tracker will be monitored and documented during individual supervisions. When a Clinical Supervisor finds that a staff member's chart is out of compliance with the treatment plan, the Clinical Supervisor will initiate an Individualized Development Plan and/or Action Plan. It is important to note that this is not a punitive measure, but a tool for the Clinical Supervisor and staff member to work together to improve compliance, and it will be reviewed regularly during supervisions.
Per SPHS Policy, a supervisor from a different site within the agency will perform a mock audit in August of 2025. This audit will function as a mock DDAP licensing visit, reinforcing our commitment to compliance, and ensuring that all aspects of charts and the physical plant are within compliance standards as established by DDAP and SPHS Policy, including Plan of Care updates every 60 days.
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