INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on March 6 & 7, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cover Forge Behavioral Health Systems at Williamsburg 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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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, that facility failed to ensure counseling was provided to clients on a regular and scheduled basis that included Individual counseling, at least twice weekly in six out of seven records reviewed.
Client #1 was admitted to a higher level of care and was stepped down to the partial level of care on January 18, 2024 and was still active at the time of the inspection. There is no documentation that the client received two individual counseling session the week of February 4, 2024.
Client #2 was admitted to a higher level of care and stepped down to the partial level of care on January 23, 2024 and was still active at the time of the inspection. There is no documentation that the client received two individual counseling sessions the week of February 26, 2024.
Client #3 was admitted to the partial level of care on November 20, 2023 and was still active at the time of the inspection. There is no documentation that the client received two individual counseling sessions the weeks of December 4, 11 and 25, 2023 and February 5, 2024.
Client #7 was admitted to a higher level of care and stepped down to the partial level of care on February 7, 2024 and was still active at the time of the inspection. There is no documentation that the client received two individual counseling sessions the weeks of February 12 and 26, 2024.
Client # 11 was admitted to a higher level of care and stepped down to the partial hospitalization level of care on May 31, 2023 and was discharged on August 30, 2023. There was no documentation that the client received two individual counseling sessions the weeks of June 5, July 3, 31 and August 7, 2023.
Client #12 was admitted to the partial level of care on November 25, 2023 and discharged on January 19, 2024. There is no documentation that the client received two individual counseling sessions the week of December 11, 2023.
These findings were received with the facility staff during the licensing process.
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Plan of Correction
Clients # 1, 2 and 3 have been discharged.
Client #7 is still in treatment and has received two individual sessions per week since the time of inspection. Individual sessions were completed on March 4, 8, 11, 12, 14, 19, 23, 26, 29 and 31.
PHP individual counselors must complete their individual session on a Sun-Saturday work week. Every Friday morning in shift report they will report to the clinical supervisor any client who does not have 2 individual sessions completed for the week yet. The clinical supervisor will either assign or complete herself the sessions that have not occurred yet for Friday and/or Saturday of that week.
The clinical supervisor is reviewing all PHP pts for the next 3 months to ensure each PHP client has 2 individual sessions per week. She will monitor 15 charts per month starting on month 4.
This POC was put in place following the annual visit. |
709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary per the facility ' s policy and procedure manual of within seven days of discharge in two out of three applicable discharged records reviewed.
Client #11 was admitted to a higher level of care and stepped down to the partial hospitalization level of care on May 31, 2023 and was discharged on August 30, 2023. A discharge summary was due no later than September 6, 2023; however, it was not completed until September 11, 2023.
Client #12 was admitted to the partial hospitalization level of care on November 25, 2023 and discharged on January 19, 2024. A discharge summary was due no later than January 26, 2024; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #12 will have a discharge summary completed by April 8, 2024.
Upon review of the discharge summary process, it was determined that the discharge summary may be handed in timely but not typed by medical records timely, therefore, the following changes to the discharge summary process will be added as the date the EMR time stamps is the date the discharge summary is typed and not completed:
PHP staff will complete the discharge summary the day of discharge. If the counselor is absent, the clinical supervisor will complete the discharge summary and send it to the medical records department. The PHP clinical supervisor is monitoring discharges daily.
Medical records will add a line to the discharge summary stating when the discharge summary was completed/received and when they type it for the EMR as these are two different dates. Medical records will also make typing a discharge summary a priority upon receiving it.
The COO will audit 15 PHP charts for discharge summary timeliness for the next 3 months.
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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 provide a complete client record, which is to include follow up information per the facility ' s policy and procedure manual of within seven days if the client has an aftercare appointment or thirty days if no appointment was scheduled in two out of three applicable discharged records.
Client #12 was admitted on November 25, 2023 and discharged on January 19, 2024. A follow up was due no later than February 19, 2024; however, there was no documentation that one was completed.
Client #13 was admitted on September 1, 2023 and discharged on October 12, 2023 A follow up was due no later than October 19, 2023; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #12 and clients #13 will have a follow up call completed by April 8, 2024.
Case management staff will be reeducated on the importance of follow up calls related to aftercare appointments.
Within 5 days of discharge, the case management supervisor will check for the completed follow up call sheet on all discharges. If the call was not completed within 5 days, the supervisor will complete the call herself to ensure it is completed within the 7 and/or 30 day range.
The COO will monitor all discharges for the next 3 months to ensure follow up calls are completed and completed timely. After 3 months, 20 charts per month will be pulled and reviewed for follow up call completeness. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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 complete psychosocial evaluation per the facility ' s policy and procedures manual of within 72 hours of admission in four out of seven records.
Client #1 was admitted to the detox level of care on December 14, 2023 and discharged on December 18, 2023 and stepped down to residential level of care on December 18, 2023 and discharged on January 18, 2024 and stepped down to the partial level of care on January 18, 2024 and was still active at the time of the inspection. A psychosocial evaluation was due no later than December 21, 2023: however, there was no documentation that one was completed.
Client #8 was admitted on January 22, 2024 and was still active at the time of the inspection, A psychosocial evaluation was due no later than January 25, 2024; however, there is no documentation that one was completed.
Client #9 was admitted to the detox level of care on February 7, 2024 and discharged on February 13, 2024 and stepped down to the residential level of care on February 13, 2024 and was still active at the time of the inspection. A psychosocial evaluation was due no later than February 16, 2024; however, it was not completed until February 28, 2024.
Client #10 was admitted to the residential level of care on January 24, 2024 and was still active at the time of the inspection. A psychosocial evaluation was due no later than January 27, 2024; however, it was not completed until February 6, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 had the biopsycho completed on 12/20/23 and the diagnostic completed on 1/18/24 which was not within 72 hours.
Client #8 had the biopsycho completed on 1/29/24 and the diagnostic completed on 3/12/24 which was not within 72 hours.
Client #9 had the biopsycho completed on 2/28/24 and the diagnostic completed on 2/28/24 which was not within 72 hours.
Clinical supervisors will reeducate the counseling staff of importance of completing the biopsychosocial within 72 hours of admission to rehab.
If a counselor is not going to get the biopsychosocial completed within 3 days, he/she must inform the clinical supervisor at the end of 48 hours so there is time to have the biopsychosocial scheduled with another counselor and/or supervisor.
COO will audit 20 charts per month until the next DDAP inspection to ensure compliance.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing and documenting follow-up information for the partial hospitalization program was submitted and approved by the Department for the March 29, 2022 and March 29, 2023 annual licensing inspections. Completing and documenting follow-up information was again found to be a deficiency in the March 6 & 7, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Operating Officer is responsible to ensure all plans of correction are followed.
He will report POC progress/compliance in our weekly management meeting.
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