INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 6, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, GPHA Al-Assist Behavioral Health 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
The facility failed to ensure that each clinical supervisor or lead counselor who has not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision.Employee # 3 was hired as a clinical supervisor on June 1, 2018. There was no documentation of the clinical supervision core curriculum training on file at the time of the inspection. The facility and employee provided documentation of various trainings completed at a local community college; however, the trainings did not receive prior approval from the Department.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Standard in Noncompliance
704.6(c) LICENSURE
Core Curriculum - Supervisor Training:
To comply with regulation 704.6. Qualifications for the position of clinical supervisor. (c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
The hiring supervisor and Director of Training and Development will attempt to schedule all newly hired or promoted supervisors who have not functioned 2- years as a clinical supervisors in the provision of clinical services to attend DDAP's core curriculum supervisory training. If the training is not available the hiring supervisor and director of training and development will submit to the Department of Drug and Alcohol Programs the supervision training curriculum of a selected college or training program prior to enrolling the newly hired or promoted employee for prior approval.
The staff member that was found out of compliance during the audit of September 6, 2019, has identified a clinical supervisor training.
The Curriculum for the training will be submitted to DDAP for prior approval, If the training is not approved by DDAP, we will seek out additional supervisory trainings until we are able to identify a supervisor training course that meets DDAP's standards. This process shall not exceed 30 days.
This process will be monitored by the HR and QA departments to ensure compliance of 704.6(c) Core Curriculum - Supervisor Training. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The facility failed to obtain an informed and voluntary consent to release information form to the funding source prior to the disclosure of information in three of seven client records reviewed. Client #1 was admitted on March 6, 2019 and was active at the time of the inspection. The facility identified one managed care organization as the primary funding source; however, there was no consent to release information form to that source as of the date of the inspection.Client #2 was admitted on September 30, 2018 and was active at the time of the inspection. There was a consent to the funding source signed and dated by the client on April 23, 2018 with an expiration date of April 23, 2019; however, there was no updated consent to release form on file as of the date of the inspection. Client # 4 was admitted on November 30, 2018 an was discharged on August 26, 2019. There was documentation of the facility billing the funding source; however, there was no consent to release to the funding source on file as of the date of the inspection.These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Plan of Correction:
Standard in Noncompliance
§ 709.28. Confidentiality (c) LICENSURE
To comply with regulation 709.28 (c), which states: The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The written findings were reviewed and researched in detail with the Leadership Team to determine how the deficiency occurred to avoid a reoccurrence of such in the future.
As a result of the meeting and research the following corrective action plan has been put in place.
Clients that initially enter into treatment as an uninsured client will be required to sign an insurance/payer consent to release authorization upon becoming insured. Along with any client that changes insurance/payers in the midst of treatment will be required to discontinue the existing consent to release authorization and to sign a new release authorization for his/her current insurance/payer.
Tracking Insurance/Payer authorizations will be conducted by the registration assistants during the appointment registration/ insurance verification process. Consent to release authorizations that fail to match current payer sources will be updated during the registration process to ensure that no client is seen without proper authorizations on file.
Daily audits of client registrations will be conducted by the Client Service Coordinator and Office Manager to ensure that standard 709.28 (c) is being enforced.
Correction Time: Correction October 23, 2019, this will allow time to correct any active client's chart currently out of compliance.
Monitoring On-going
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709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The facility failed to document the purpose of disclosure on the consent form in one of seven client records.Client # 4 was admitted on November 30, 2018 and was discharged on August 26, 2019. There was a consent to release form to a probation officer signed and dated December 27, 2018; however, the consent to release form did not specify the purpose for disclosure.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Standard in Noncompliance
§ 709.28 (c)(3) Licensure
Confidentiality:
To comply with regulation 709.28 (c)(3) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to: (3) Purpose of disclosure.
The electronic consent forms were updated July 2019, and replaced with the following options under Purpose of disclosure: Authorize Care, Facilitate Claims, Monitor Services, Continuity of Care, Service Transfer, SSI/SSDI Review, Court Compliance and Other, which requires specification. Staff were trained on the revised consent form in July 2019.
However, Effective September 23, 2019, Clients who signed consents to release prior to the revisions that took place in July 2019, are now required to resign their consents. To ensure that all active Clients are using the revised consent form which includes a designated required field for purpose of disclosure.
A random audit of each therapist caseload will be conducted periodically by the Clinical Supervisor to ensure that standard 709.28 is being followed properly.
Overall Correction Time: October 23, 2019, this date allows for the programs ability to capture all Clients considered active.
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709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
The facility failed to document the dated signature of a client on a consent to release information form in one of seven client records.Client # 4 was admitted on November 30, 2018 and was discharged on August 26, 2019. There was a consent to release form to a probation officer dated December 27, 2018; however, the consent form did not include the dated client signature.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
Standard in Noncompliance
709.28 (c)(4) Confidentiality:
To comply with regulation 709.28 (c)(4), the written findings from the September 6, 2019 were reviewed in detail with the Clinical Team. The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to: (4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
To achieve and maintain compliance with capturing the date in which a signature was obtained. The dated signature field of the client was made mandatory in July 2019.
Effective September 23, 2019, Clients who signed consents prior to the revisions that took place in July 2019, are now required to resign their consents. To ensure that all active Clients are using the revised consent form which includes the witness capture signature in addition to the EHR electronic signature.
A random audit of each therapist caseload will be conducted periodically by the Clinical Supervisor to ensure that standard 709.28 is being followed properly.
Overall Correction Time: October 23, 2019, this date allows for the programs ability to capture all Clients considered active.
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709.28 (c) (5) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
The facility failed to document a dated witness signature on every consent to release information form in each client record reviewed.Client # 1 was admitted on March 6, 2019 and was active at the time of the inspection.Client # 2 was admitted on September 30, 2016 and was active at the time of the inspection.Client # 3 was admitted on October 4, 2018 and was discharged on August 23, 2019.Client # 4 was admitted on November 30, 2018 and was discharged on August 26, 2019.Client # 5 was admitted on November 16, 2018 and was active at the time of the inspection.Client # 6 was admitted on December 4, 2018 and was discharged on May 17, 2019.Client # 7 was admitted on April 22, 2019 and was discharged on August 20, 2019.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
Standard in Noncompliance
709.28 (c)(5) Confidentiality:
To comply with regulation 709.28 (c)(5), the written findings from the September 6, 2019 were reviewed in detail with the Clinical Team. It was confirmed in June 2019, that the EHR system's electronic signature process met the conditions necessary for electronic signatures under HIPAA law and in consideration of the Uniform Electronic Transaction Act (UETA) and the Global and National Commerce Act (ESIGN Act) and is in full compliance.
However, to achieve compliance with ESIGN and add instant visual compliance for regulation 709.28 (c) (5) an additional field was added to the existing electronic consent forms indicating the language Dated signature of witness. This field was made mandatory in July 2019.
Effective September 23, 2019, Clients who signed consents prior to the revisions that took place in July 2019, will be required to resign their consents. To ensure that all active Clients are using the revised consent form which includes the witness capture signature in addition to the EHR electronic signature.
A random audit of each therapist caseload will be conducted periodically by the Clinical Supervisor to ensure that standard 709.28 is being followed properly.
Overall Correction Time: October 23, 2019, this date allows for the programs ability to capture all Clients considered active.
Monitoring On-going by QA Department
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709.28 (c) (6) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
The facility failed to document the date, event or condition upon which the consent will expire in three of seven client records reviewed. Client # 5 was admitted on November 16, 2018 and was active at the time of the inspection. There was a consent to the funding source signed and dated by the client on November 29, 2017; however, it did not include an expiration date.Client # 6 was admitted on December 4, 2018 and was discharged on May 7, 2019. There were consent forms to a probation officer, a primary care physician and a urinalysis laboratory signed and dated by the client on December 4, 2018; however, the did not include an expiration date.Client # 7 was admitted to the on April 22, 2019 and was discharged on August 20, 2019. There was a consent to the funding source signed and dated by the client on April 22, 2019; however, it did not include an expiration date.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction
Standard in Noncompliance
709.28 (c) (6) LICENSURE
Confidentiality:
To comply with regulation § 709.28. Confidentiality. (c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to: (6) Date, event or condition upon which the consent will expire.
The electronic consent form was revised to indicate the following: The consent will expire 6-months after date of discharge or unless revoked sooner by clients.
Effective September 23, 2019, Clients who signed consents prior to the revisions that took place in July 2019, are now required to resign their consents. To ensure that all active Clients are using the revised consent form which indicates Date, event or condition upon which the consent will expire.
A random audit of each therapist caseload will be conducted periodically by the Clinical Supervisor to ensure that standard 709.28 (C)(6) is being followed properly.
Overall Correction Time: October 23, 2019, this date allows for the programs ability to capture all Clients considered active.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to provide documentation that verified that the client was given written acknowledgement that they had been informed that when they are receiving care or treatment under section 7 of the act (71 P. S. 1690.107), they shall retain all their civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment in every client record reviewed.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Standard in Noncompliance:
709.30 (1) Client rights:
§ 709.30. Client rights.
To achieve full compliance with regulation 709.30 (1), A meeting was held with the Clinical Leadership Team resulting in a review of the revisions made to the Electronic Client Rights and Responsibility Form in June 2019.
The current electronic Client Rights and Responsibility from meets the full requirements of 709.30 particularly 709.30 (1) A Clients receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by stature. No Client may be deprived of a civil right solely by reason of treatment.
Effective September 23, 2019, to ensure that all active Clients have electronically reviewed, signed and received the correct Client Rights and Responsibility form, all active Clients will be required to review and update the Client Rights and Responsibility electronic form during the next scheduled appointment.
The QA Department along with the Site Directors will conduct random audits over the next 31-days to ensure that all active clients are captured and quarterly thereafter to maintain compliance. Data collected during these audits will be immediately shared with the Clinical Leadership Team and QA EHR Specialist for immediate resolve if needed.
Completion Time: Completed
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
The facility failed to provide documentation verifying that the client had been given written acknowledgement that they had been informed that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in one of seven client records reviewed. Client # 7 was admitted on April 22, 2018 and was discharged on August 20, 2019. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Standard in Noncompliance:
709.30 (2) Client rights:
§ 709.30. Client rights.
To achieve full compliance with regulation 709.30 (4), A meeting was held with the Clinical Leadership Team resulting in a review of the revisions made to the Electronic Client Rights and Responsibility Form in June 2019.
The current electronic Client Rights and Responsibility from meets the full requirements of 709.30 particularly 709.30 (2) written acknowledgement that they had been informed that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in one of seven client records reviewed.
Effective September 23, 2019, to ensure that all active Clients have electronically reviewed, signed and received the correct Client Rights and Responsibility form, all active Clients will be required to review and update the Client Rights and Responsibility electronic form during the next scheduled appointment.
The QA Department along with the Site Directors will conduct random audits over the next 31-days to ensure that all active clients are captured and quarterly thereafter to maintain compliance. Data collected during these audits will be immediately shared with the Clinical Leadership Team and QA EHR Specialist for immediate resolve if needed.
Completion Time: Completed
Monitoring: On-going
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
The facility failed to provide documentation verifying that the client had been given written acknowledgement that they had been informed that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if that director determines that the information may be detrimental if presented to the client and the reasons for the removal of such sections shall be documented in the record in every client record reviewed.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Standard in Noncompliance:
709.30 (3) Client rights:
§ 709.30. Client rights.
To achieve full compliance with regulation 709.30 (3), A meeting was held with the Clinical Leadership Team resulting in a review of the revisions made to the Electronic Client Rights and Responsibility Form in June 2019.
The current electronic Client Rights and Responsibility from meets the full requirements of 709.30 particularly 709.30 (3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
Effective September 23, 2019, to ensure that all active Clients have electronically reviewed, signed and received the correct Client Rights and Responsibility form, all active Clients will be required to review and update the Client Rights and Responsibility electronic form during the next scheduled appointment.
The QA Department along with the Site Directors will conduct random audits over the next 31-days to ensure that all active clients are captured and quarterly thereafter to maintain compliance. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
The facility failed to provide documentation verifying that the client had been given written acknowledgement that they had been informed that all clients have the right to appeal, to the director, a decision limiting access to their records in each client record reviewed.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Standard in Noncompliance:
709.30 (4) Client rights:
§ 709.30. Client rights.
To achieve full compliance with regulation 709.30 (4), A meeting was held with the Clinical Leadership Team resulting in a review of the revisions made to the Electronic Client Rights and Responsibility Form in June 2019.
The current electronic Client Rights and Responsibility from meets the full requirements of 709.30 particularly 709.30 (4) Clients have the right to appeal a decision limiting access to their records to the director.
Effective September 23, 2019, to ensure that all active Clients have electronically reviewed, signed and received the correct Client Rights and Responsibility form, all active Clients will be required to review and update the Client Rights and Responsibility electronic form during the next scheduled appointment.
The QA Department along with the Site Directors will conduct random audits over the next 31-days to ensure that all active clients are captured and quarterly thereafter to maintain compliance. Data collected during these audits will be immediately shared with the Clinical Leadership Team and QA EHR Specialist for immediate resolve if needed.
Completion Time: Completed
Monitoring: On-going
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
The facility failed to provide documentation verifying that the client had been given written acknowledgement that they had been informed that all clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in every client record reviewed.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Standard in Noncompliance:
§ 709.30 (5) Client rights:
To achieve full compliance with regulation 709.30 (5), A meeting was held with the Clinical Leadership Team resulting in a review of the revisions made to the Electronic Client Rights and Responsibility Form in June 2019.
The current electronic Client Rights and Responsibility from meets the full requirements of 709.30 particularly 709.30 (5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Effective September 23, 2019, to ensure that all active Clients have electronically reviewed, signed and received the correct Client Rights and Responsibility form, all active Clients will be required to review and update the Client Rights and Responsibility electronic form during the next scheduled appointment.
The QA Department along with the Site Directors will conduct random audits over the next 31-days to ensure that all active clients are captured and quarterly thereafter to maintain compliance. Data collected during these audits will be immediately shared with the Clinical Leadership Team and QA EHR Specialist for immediate resolve if needed.
Completion Time: Completed
Monitoring: On-going
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709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
The facility failed to provide documentation verifying that the client had been given written acknowledgement that they had been informed that all clients have the right to submit rebuttal data or memoranda to their own records in one of seven client records reviewed.Client # 7 was admitted on April 22, 2018 and was discharged on August 20, 2019. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
Standard in Noncompliance:
§ 709.30 (6) Client rights:
To achieve full compliance with regulation 709.30 (6), A meeting was held with the Clinical Leadership Team resulting in a review of the revisions made to the Electronic Client Rights and Responsibility Form in June 2019.
The current electronic Client Rights and Responsibility from meets the full requirements of 709.30 particularly 709.30 (6) that all clients have the right to submit rebuttal data or memoranda to their own records.
Effective September 23, 2019, to ensure that all active Clients have electronically reviewed, signed and received the correct Client Rights and Responsibility form, all active Clients will be required to review and update the Client Rights and Responsibility electronic form during the next scheduled appointment.
The QA Department along with the Site Directors will conduct random audits over the next 31-days to ensure that all active clients are captured and quarterly thereafter to maintain compliance. Data collected during these audits will be immediately shared with the Clinical Leadership Team and QA EHR Specialist for immediate resolve if needed.
Completion Time: Completed
Monitoring: On-going
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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
The facility failed to document a psychosocial evaluation in four of seven client records reviewed.Client # 4 was admitted on November 30, 2018 and was discharged on August 26, 2019. Client # 5 was admitted on November 16, 2018 and was active at the time of the inspection.Client # 6 was admitted on December 4, 2018 and was discharged on May 17, 2019. Client # 7 was admitted on April 22, 2019 and was discharged on August 20, 2019. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Standard in Non-Compliance
709.91(b)(6) LICENSURE
Intake and Admission:
In an effort to achieve full compliance with regulation 709.91(b)(6), the findings from September 6, 2019, were reviewed by the Chief Behavioral Healthcare Officer, Site Director, Clinical Supervisor, QA Manager and select counselors. As a result of the findings and full review of the cases found in non-compliance the following corrective action plan has been implemented.
A full DDAP audit review occurred with the BH Division Leadership Team on Wednesday, September 18, 2019, to determine all gaps in the Programs ability to effectively and efficiency meet standard 709.91 (b) (6) with 100% accuracy. As a result of these meetings: a refresher training held on September 27, 2019, for all counselors deemed as needing additional instruction/support in completing a comprehensive clinical evaluation summary that fully meets Standard 709.91(b)(6) LICENSURE Intake and Admission, immediately following the completion of the CBE.
Charts found out of compliance for Standard 709.91, will be brought into compliance prior to 10/18/2019.
In addition, an in-service is scheduled for October 18, 2019, to review how to fully utilize the electronic evaluation tools to assist in completing the evaluation summary.
Monitoring: The Quality Assurance Clerk will conduct weekly audits based on scheduled CBE appointments to ensure a psychosocial evaluation summary has been completed. Any Non-Compliance will be emailed to both the Clinician and supervisor for immediate correction.
The Clinical Supervisor will conduct weekly reviews to ensure that all aspects of the 709.91 is in compliance with standard 709.91 (b) (6).
TIME FRAME FOR COMPLETION:
October 18, 2019
? Ongoing Monitoring
Evaluation of Monitoring Process
Every 30-days by Quality Assurance Manager and Site Director will conduct targeted audits to ensure compliance.
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709.92(a) 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:
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Observations
The facility failed to properly document the type and frequency of services the client was to receive on the comprehensive treatment and rehabilitation plan in five of six applicable client records reviewed. Additionally, the facility failed to document supportive services on the comprehensive treatment and rehabilitation plan in two of six applicable client records reviewed.Client # 1 was admitted on March 6, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was completed on August 21, 2019. The type and frequency of services was not included on the treatment plan. Additionally, the treatment plan did not include supportive services. Client # 3 was admitted on October 4, 2018 and was discharged on August 23, 2019. The comprehensive treatment plan was completed on December 20, 2018. The type and frequency of services was not included on the treatment plan. Additionally, the treatment plan did not include supportive services. Client # 4 was admitted on November 30, 2018 and was discharged on August 26, 2019. The comprehensive treatment plan was completed on April 12, 2019. The type and frequency of services was not included on the treatment plan. Client # 5 was admitted on November 16, 2018 and was still active at the time of the inspection. The comprehensive treatment plan was completed on December 5, 2018. The type and frequency of services was not included on the treatment plan. Client # 6 was admitted on December 4, 2018 and was discharged on May 17, 2019. The comprehensive treatment plan was completed on December 18, 2018. The type and frequency of services was not included on the treatment plan.
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Plan of Correction
709.92 (a) LICENSURE
TREATMENT AND REHABILITATION SERVICES:
In an effort to achieve full compliance with regulation 709.92(a) the findings from the September 6, 2019, audit was reviewed by the Chief Behavioral Healthcare Officer, Site Director and Clinical Coordinator. As a result of the findings and full review of the cases found in non-compliance the following corrective action plan has been implemented at this facility.
During each Morning and Afternoon huddle, the site's Clinical Leadership team will reiterate as instructed in previous Treatment Plan trainings the importance of completing treatment plans as required by Standard 709.92(a) Licensure Treatment and Rehabilitation: - Documenting the type and frequency of treatment and rehabilitative services
along with, Treatment Plan required time-lines for initiating and updating, treatment plans: How to handle compliant clients and non-compliant clients when Treatment Plans are due or up for review. Reinforcing that treatment plans must be updated within the scheduled time frame, noting all scheduled clients that are due for an update within the next 1-14-days. Emphasizing that any scheduled client that fails to keep his/her scheduled appointment today treatment plan must be updated on their behalf by the assigned clinician. Said treatment plan will be signed by the Clinician, Clinical Supervisor and Site Psychiatrist and reviewed with Client at the next kept appointment Any requested revisions will be updated, signed and finalized at the time of the Clients next kept appointment.
Charts that were found out of compliance during the scheduled audit will unfortunately remain out of compliance for the time-period in which a lapse in compliance occurred. A treatment plan could and will be added to the system indicating the dates of the lapse time-period. However, the completion date in which the actual treatment plan was completed will be indicated as the actual completion date.
Therefore, reinforcing our failure to complete the treatment plan within the appropriate time-frame.
Our goal is to develop a corrective action plan to avoid such mishaps moving forward while offering our staff more support and reinforcement.
In addition, during supervision sessions the Clinical Supervision will reiterate the importance of completing Treatment Plans according to standards and program policy.
Additional individualize support and formulation of performance improvement plans if needed for: Developing Comprehensive Treatment Plans, implementing evidence based practices when establishing type and frequency of rehabilitation services. Developing Treatment Plans Up-Dates, Adherence to Treatment Plan Timelines and Effectively Managing Clients to Maintain Compliance will be completed and reviewed evaluated.
Monitoring: The Quality Assurance Clerk will conduct daily audits along with audits based on the Clients' schedule 48-hours in advance to ensure that Treatment Plans are updated in accordance with regulation 709.92 and policy. The Clinical Supervisor will conduct weekly reviews to ensure that all aspects of the treatment plan are in compliance with standard 709.92.
TIME FRAME FOR COMPLETION:
Ongoing Monitoring
Evaluation of Monitoring Process
Every 60-days by Quality Assurance Manager and Site Director
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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
The facility failed to provide treatment plan updates within the regulatory timeframe in four of seven applicable client records reviewed.Client # 2 was admitted on September 30, 2016 and was still active at the time of the inspection. A treatment plan update was completed on July 23, 2018 with an update due no later than September 23, 2018; however, the update wasn't completed until January 19, 2019. Additionally, A treatment plan update was completed on March 27, 2019 with an update due no later than May 27, 2019; however, there was no update completed as of the date of the inspection.Client # 4 was admitted on November 30, 2018 and was discharged on August 26, 2019. The comprehensive treatment and rehabilitation plan were completed on April 12, 2019 with an update due no later than June 12, 2019; however, there was no update completed prior to discharge.Client # 5 was admitted on November 16, 2018 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was completed on December 5, 2018 with an update was due no later than February 5, 2019; however, the update wasn ' t completed until April 2, 2019.Client # 6 was admitted on December 4, 2018 and was discharged on May 17, 2019. The comprehensive treatment and rehabilitation plan was completed on December 18, 2018 with an update was due no later than February 18, 2019; however, there was no update completed prior to discharge.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92 (b) LICENSURE
TREATMENT AND REHABILITATION SERVICES:
In an effort to achieve full compliance with regulation 709.92(b) the findings from the September 6, 2019, audit was reviewed by the Chief Behavioral Healthcare Officer, Site Director and Clinical Coordinator. As a result of the findings and full review of the cases found in non-compliance the following corrective action plan has been implemented at this facility.
During each Morning and Afternoon huddle, the site's Clinical Leadership team will reiterate as instructed in previous Treatment Plan trainings the importance of completing treatment plans as required by Standard 709.92(b) Licensure Treatment and Rehabilitation: Treatment Plan required time-lines for initiating and updating: How to handle compliant clients and non-compliant clients when Treatment Plans are due or up for review. Reinforcing that treatment plans must be updated within the scheduled time frame, noting all scheduled clients that are due for an update within the next 1-14-days. Emphasizing that any scheduled client that fails to keep his/her scheduled appointment today treatment plan must be updated on their behalf by the assigned clinician. Said treatment plan will be signed by the Clinician, Clinical Supervisor and Site Psychiatrist and reviewed with Client at the next kept appointment Any requested revisions will be updated, signed and finalized at the time of the Clients next kept appointment.
Charts that were found out of compliance during the scheduled audit will unfortunately remain out of compliance for the time-period in which a lapse in compliance occurred. A treatment plan could be added to the system indicating the dates of the lapse time-period. However, the completion date in which the actual treatment plan was completed will be indicated as the actual completion date. Therefore, reinforcing our failure to complete the treatment plan within the appropriate time-frame.
Our goal is to develop a corrective action plan to avoid such mishaps moving forward.
In addition, during supervision sessions the Clinical Supervision will reiterate the importance of completing Treatment Plans according to standards and program policy. Additional individualize support and formulation of performance improvement plans if needed for: Developing Comprehensive Treatment Plans, Developing Treatment Plans Up-Dates, Adherence to Treatment Plan Timelines and Effectively Managing Clients to Maintain Compliance will be completed and reviewed evaluated.
Monitoring: The Quality Assurance Clerk will conduct daily audits along with audits based on the Clients' schedule 48-hours in advance to ensure that Treatment Plans are updated in accordance with regulation 709.92 and policy. The Clinical Supervisor will conduct weekly reviews to ensure that all aspects of the treatment plan are in compliance with standard 709.92.
TIME FRAME FOR COMPLETION:
Ongoing Monitoring
Evaluation of Monitoring Process
Every 60-days by Quality Assurance Manager and Site Director
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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
The facility failed to provide a complete client record, which is to include case consultation notes and follow up information, in five of seven client records.Client # 2 was admitted on September 30, 2016 and was active at the time of the inspection. The record was missing documentation of the completion of case consultation notes.Client #3 was admitted on October 4, 2018 and was discharged on August 23, 2019. The record was missing documentation of the completion of case consultation notes. Client # 4 was admitted on November 30, 2018 and was discharged on August 26, 2019. The record was missing documentation of the completion of case consultation notes. Client #5 was admitted on November 16, 2018 and was active at the time of the inspection. The record was missing documentation of the completion of case consultation notes. Client #6 was admitted on December 4, 2018 and was discharged on May 17, 2019. The record was missing documentation of the completion of case consultation notes. Additionally, the record was missing documentation of any follow-up information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.93 (a)(8)LICENSURE
CLIENT RECORD
In an effort to reestablish and maintain compliance as it relates to Standard 709.93 (a)(8), the following corrective action plan has been put in place:
An in-service review of the Case Consultation policy and standard 709.93(a)(8), has been added to the scheduled in-service of October 18, 2019. During this in-service staff will be given a pre-post test of the regulations and protocol. Training emphases will be placed on the following: The Purpose of Conducting Case Consultations, Case Consultation Timelines, Electronic Form Completion, Recording the Treatment Recommendations Electronically during the Case Consult and Obtaining Signatures of Participants. All newly hired clinical staff will receive this training during orientation.
Failure of the post-test will require 1-1 support from the assigned supervision and a retaking of the post-test.
A targeted case consultation session will be held before October 18, 2019, with Counselors for Clients' Charts that were out of compliance during the audit of 9/6/2019. Prior to this targeted case consultation session, case consultations will be completed electronically and prepared for oral presentation, followed by immediate feedback entered electronically into the system. The site director will be responsible for monitoring this process and reporting the final results to the Leadership team during the next scheduled meeting following the targeted case consultation session.
In addition, the development of a case consultation compliance report(tool) has been requested from the IS/EHR Specialist. Upon completion of the requested report, Counselors and supervisors will be able to monitor case consultation due dates and recommendations with accuracy.
Monitoring of Case Consultation Compliance will be completed monthly by the quality control clerks.
Content and compliance will be randomly be monitored by the site directors.
The monitoring process will be reviewed quarterly by the QA Department to ensure compliance. Findings from this review will be shared during the Leadership meeting for additional strategies to improve the process if needed.
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