INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 19-21, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Al-Assist Behavioral Healthcare 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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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 the review of client records, the facility failed to document the clients' medical, drug and alcohol, and/or personal history as stated in agency policy in two of six client records.The findings include:The policy referring to the comprehensive biopsychosocial assessment, which includes the medical, drug and/or alcohol, and personal histories states that the comprehensive biopsychosocial assessment is to be completed within fifteen working days. Six client records requiring documentation of histories were reviewed on August 20-21, 2013. The facility failed to document all or some of the client history components in client records # 1 and 2.Client #1 was admitted to treatment on December 20, 2012. As of the date of inspection, there was no documentation of a medical, drug and alcohol, or personal history for client #1. Client #2 was admitted to treatment on March 1,2013. As of the date of inspection, there was no documentation of a medical, drug and alcohol, or personal history for client # 2. The findings were reviewed with quality assurance staff, the clinical director, and the facility director during the exit interview.
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Plan of Correction
709.91 (b)(3)(i)
INTAKE and ADMISSION
Based on a review of client records, the facility failed to document the client's medical, drug/alcohol, and/or personal history as stated in the agency's policy in two of six client records.
CORRECTIVE ACTION
The findings of 2013 DDAP Licensure Renewal Inspection will be disseminated and reviewed with Clinical Coordinators at the next scheduled Management Meeting. The Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will conduct a training for all Drug/Alcohol Counselors on the Comprehensive Bio-Psychosocial Evaluation (CBE), which will include the following training areas:
- time frame for completing the CBE.
- instructions for fully completing the medical history section.
- instructions for fully completing the drug/alcohol history section.
- instructions for completing the personal history section.
- required areas to be assessed/ evaluated when completing CBE's.
- strategies to ensure that CBE's are evaluative, and reflect the Counselor's conclusions/impressions.
Additionally, the Drug/Alcohol Clinical Coordinator and Quality Assurance Clerks will monitor records weekly to ensure that the CBE's are completed in accordance with GPHA, Inc's CBE policies/procedures, and DDAP regulations. All newly hired clinical staff will also receive this training during their orientation period.
TIME FRAME FOR COMPLETION
October 15, 2013-Combined Training \ Ongoing Monitoring
PERSONS RESPONSIBLE
Coordinator of Behavioral Health, Drug/Alcohol Clinical Coordinator, Quality Assurance Coordinator
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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 the clients' psychosocial assessment as stated in agency policy in three of six client records.The findings include:The policy referring to the comprehensive biopsychosocial assessment, which includes the psychosocial evaluation stated that art 2 of the comprehensive biopsychosocial assessment is to be completed within thirty working days. Six client records requiring documentation of a psychosocial evaluation were reviewed on August 20-21, 2013. The facility failed to document psychosocial evaluations in client records # 1,2 and 4.Client # 1 was admitted to treatment on December 20, 2012. As of the date of inspection, there was no documentation of a psychosocial evaluation for client # 1. Client # 2 was admitted to treatment on March 1, 2013. As of the date of inspection, there was no documentation of psychosocial evaluation for client # 2. Client # 4 was admitted to treatment on January 24, 2013 and discharged on June 10, 2013. As of the date of inspection, there was no documentation of a psychosocial evaluation for client # 4. The findings were reviewed with quality assurance staff, the clinical director, and the facility director during the exit interview.
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Plan of Correction
709,91(b)(6)
INTAKE and ADMISSION
Based on a review of the client records, the facility failed to document the client's psychosocial assessment (Clinical Impression) in three of six client records.
CORRECTIVE ACTION
The findings of the 2013 DDAP License Renewal Inspection will be disseminated and reviewed with Clinical Coordinators at the next scheduled Management Meeting. The Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will conduct a training for Drug/Alcohol Counselors on the Comprehensive Bio-Psychosocial Evaluation (CBE), which will cover the following training areas:
- time frame for completing the CBE -Clinical Impression.
- required areas to be assessed and evaluated when completing the CBE -Clinical Impression.
- strategies to ensure that the CBE -Clinical Impressions are evaluative, and reflect the Counselor's conclusions and impressions.
Additionally, the Drug/Alcohol Clinical Coordinator and Quality Assurance Clerks will monitor records weekly to ensure that the CBE-Clinical Impressions are completed in accordance with GPHA. Inc's CBE policies/procedures, and DDAP regulations. All newly hired clinical staff will receive this training during their orientation period.
TIME FRAME FOR COMPLETION
October 15, 2013-Combined Training / Ongoing Monitoring
PERSONS RESPONSIBLE
Drug/Alcohol Clinical Coordinator, Coordinator of Behavioral Health, Quality Assurance Coordinator
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include the type and frequency of treatment and rehabilitation services. The findings include:Six client records were reviewed for treatment plans on August 20-21, 2013. Five out of six client records lacked documentation of a treatment plan that included the type and frequency of treatment and rehabilitation services, specifically client records # 1,2, 4, 5, and 6. The treatment plan for client # 1 was completed on January 26, 2013 and did not include the frequency of treatment and rehabilitation services.Client # 2 was admitted on March 1, 2013 and still active at the time of inspection. As of the date of inspection, there has not been a treatment plan completed at all for client #2. The treatment plan for client # 4 was completed on February 7, 2013 and did not include the type and frequency of treatment and rehabilitation services.The treatment plan for client # 5 was completed on June 21, 2013 and did not include the type and frequency of treatment and rehabilitation services.The treatment plan for client #6 was completed on February 15, 2013 and did not include the type and frequency of treatment and rehabilitation services.The findings were reviewed with quality assurance staff, the clinical director, and the facility director during the exit interview.
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Plan of Correction
709.92(a)(2)
TREATMENT and REHABILITATION SERVICES
Based on a review of client records, the facility failed to document treatment plans to include the type and frequency of treatment and rehabilitation services.
CORRECTIVE ACTION
The 2013 DDAP Licensing Renewal Inspection findings will be disseminated and reviewed with Coordinators at the next scheduled Management Meeting. The Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will conduct a training with Drug/Alcohol Counselors to cover the following areas:
- time frame for completion of comprehensive treatment plans and treatment plan updates.
- instructions for including types and frequency of treatment and rehabilitation services in all treatment plans.
- instructions for including clear and measurable treatment goals and objectives in treatment plans.
Also, the Drug/Alcohol Clinical Coordinator and Quality Assurance Clerks will monitor client records weekly to ensure that they are completed in accordance with GPHA, Inc's treatment plan policies/procedures, and DDAP standards. All newly hired clinical staff will receive this training during their orientation period.
TIME FRAME FOR COMPLETION
October 15, 2013-Combined Training / Ongoing Monitoring
PERSONS RESPONSIBLE
Drug/Alcohol Clinical Coordinator, Quality Assurance Coordinator, Coordinator of Behavioral Health
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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 a review of client records, the facility failed to document a complete client record to include a discharge summary in one out of three client records. The findings include:Six client records were reviewed on August 20-21, 2013, three of those records were required to document a discharge summary. One out of three client records failed to include documentation of a discharge summary, specifically client record # 6. Client # 6 was admitted January 17, 2013 and discharged on August 5, 2013. As of the date of inspection, there was no documentation of a discharge summary for client # 6. . The findings were reviewed with quality assurance staff, the clinical director, and the facility director during the exit interview.
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Plan of Correction
709.92(a)(3)
TREATMENT and REHABILITATION SERVICES
Based on the review of client records, the facility failed to document a complete client record to include a discharge summary, in one of three client records.
CORRECTIVE ACTION
The 2013 DDAP Licensing Renewal Inspection findings will be disseminated and reviewed with Coordinators at the next scheduled Management Meeting. The Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will conduct a training with Drug/Alcohol Counselors to cover the following:
- description of the client's course of treatment.
- client's progress or lack of progress in treatment.
- type of discharge.
- unresolved treatment issues.
- client's prognosis.
Additionally, the Drug/Alcohol Clinical Coordinator and Quality Assurance Clerks will monitor client discharge records weekly to ensure that discharge summaries are completed in accordance with GPHA, Inc's client discharge policies/procedures, and DDAP regulations. All newly hired clinical staff will receive this training during their orientation period.
TIME FRAME FOR COMPLETION
October 15, 2013-Combined Training / Ongoing Monitoring
PERSONS RESPONSIBLE
Drug/Alcohol Clinical Coordinator, Quality Assurance Coordinator, Coordinator of Behavioral Health Services.
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