INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 4, 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, 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to provide documentation of an individual training plan for the current training year in 1 of 13 employee records reviewed.Employee # 12 was hired as a counselor on May 7, 2018. There was no documentation of an individual training plan for the current year, which was identified as January 1, 2019 December 31, 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Standard in Non-Compliance
704.11(b)(1): Individual Training Plan
In an effort to address the non-compliance of standard 704.11(b)(1): Individual Training Plan
The Leadership Team reviewed the current policies in place for Staff Development/Training along with the 28 PA Code as it relates to the findings.
In addition, the Leadership team investigated how the program failed to meet the above standard. According to the agency's policy in support of this standard, comprehensive training assessments are scheduled to be completed by the assigned supervisor with input from the staff: for each staff member during the last quarter of the current year in preparation for continued staff development/training in the upcoming year. The Site Director must review each individual's training needs assessment and developmental plan ensuring relevancy, accuracy and completion of the documents. A copy of the training assessments/development plan will be maintained in the training assessment/development plan binder. The original will be placed in each staff members' personnel record.
Findings from the investigation revealed that all steps in the policy were followed with the exception of forwarding a copy of the training assessment/development plan to be placed in the training assessment/development plan binder.
To avoid any future infractions of 704.11(b)(1),the QA Department will complete a targeted audit of Individual Training/Development Plans on December 20, 2019, Future targeted audits of Individual Training/Development Plans will occur the 3rd Friday of December, to ensure that all Individual Training/ Development Plans are completed and properly filed prior to year end.
The QA Dept. will present the findings immediately following the scheduled audit, any infractions will be addressed prior to the close of business on the date audited. Any new hires after the targeted audit date, will receive an Individual Training/Development Plan during the orientation process.
Monitoring: On-going by Site Directors and QA Department.
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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 April 12, 2019 and was still active at the time of the inspection.Client # 2 was admitted on February 6, 2019 and was still active at the time of the inspection.Client # 3 was admitted on January 30, 2019 and was still active at the time of the inspection.Client # 4 was admitted on November 30, 2018 and was discharged on April 9, 2019.Client # 5 was admitted on January 11, 2019 and was discharged on May 28, 2019.Client # 6 was admitted on January 9, 2019 and was discharged on August 8, 2019.Client # 7 was admitted on November 28, 2018 and was discharged on March 1, 2019.The findings were reviewed with facility staff during the licensing inspection.
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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 4, 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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709.30 (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 had 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
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 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. 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 |
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 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 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 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 (5) Client rights:
§ 709.30. 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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709.91(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 two of seven client records reviewed.Client # 2 was admitted on February 6, 2019 and was active at the time of the inspection.Client # 4 was admitted on November 30, 2018 and was discharged on April 9, 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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 4, 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 occurred 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.
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 follows 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(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 three of seven applicable client records reviewed.Client # 5 was admitted on January 11, 2019 and was discharged on May 28, 2019. The comprehensive treatment and rehabilitation plan was completed on January 24, 2019 with an update due no later than March 24, 2019; however, there was no update completed prior to discharge.Client # 6 was admitted on January 9, 2019 and was discharged on August 8, 2019. The comprehensive treatment and rehabilitation plan was completed on January 9, 2019 with an update due no later than March 9, 2019; however, there was no update completed prior to discharge.Client # 7 was admitted on November 28, 2018 and was discharged on March 1, 2019. The comprehensive treatment and rehabilitation plan was completed on November 28, 2018 with an update was due no later than January 28, 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
Standard in Non-Compliance
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 4, 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.
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 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:
Monitoring - Ongoing
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 in five of seven client records.Client # 2 was admitted on February 6, 2019 and was active at the time of the inspection. The record was missing documentation of the completion of case consultation notes.Client #4 was admitted on November 30, 2018 and was discharged on April 9, 2019. The record was missing documentation of the completion of case consultation notes. Additionally, the record was missing documentation of any follow-up information.Client # 5 was admitted on January 11, 2019 and was discharged on May 28, 2019. The record was missing documentation of the completion of case consultation notes. Additionally, the record was missing documentation of any follow-up information.Client #6 was admitted on January 9, 2019 and was discharged on August 8, 2019. The record was missing documentation of the completion of case consultation notes. Additionally, the record was missing documentation of any follow-up information.Client #7 was admitted on November 28, 2018 and was discharged on March 1, 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
Standard in Non-Compliance
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.
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.
Monitoring On-going
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