INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 23, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, GPHA Dental and Behavioral Health 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics within the regulatory timeframe in one of six applicable personnel records reviewed. Employee #6 was hired as a counselor on January 18, 2022 and was due to receive a minimum of six hours of HIV/AIDS training and four hours of TB/STD training no later than January 18, 2022; however, there was only documentation of 2 hours of HIV/AIDS and 3 hours of TB/STD trainings as of the date of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To comply with Standard 704.11 (c)(1) Licensure Mandatory Communicable Disease Training: All new hires will be required to attend the BHTEN DDAP approved trainings to meet all the required topics and hours of training specified in Standard 704.11 (c)(1). Registration for the required training will commence during orientation to ensure that all required training hours are obtained within the required time period.
The employee deemed out of compliance during the site visit has been scheduled to complete the required training.
Required training are monitored by the Training and Development Director, Supervisor, and Quality Assurance Director at the following intervals, pre-start date, orientation, and quarterly to ensure that required trainings along with annual CEU hours are obtain. Moving forward, this team of auditors will monitor to ensure that all DDAP training is completed by BHTEN and/or DDAP for specific trainings.
Findings from the Training audits will be reviewed quarterly during the BH Leadership Meeting to monitor compliance. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client in one of seven client records reviewed.Client #2 was admitted on November 7, 2022 and was discharged on March 29, 2023. A release of information form to a pre-trial service agency was signed and dated by the client on November 7, 2022; however, there was no documentation, in the record, that a copy of the consent form was offered to the client. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to comply with Standard 709.28(d) Confidentiality (d) A copy of a client consent shall be maintained in the record.
In an effort to comply with 709.28(d) written notification of offering the client a copy of their consent form is now a required field on the consent form to avoid careless human errors of not completing the entire consent form. All fields must be completed prior to submitting the form Electronically.
Furthermore, AD Dept. and Clinical supervisors will review completed intakes on a weekly basis during scheduled Admission and Discharge Committee meetings to ensure that documentation particularly consents are completed according to standards and within regulatory guidelines.
The supervisors will also review authorizations during biweekly supervision meetings with urgent care providers and report findings back to Site director,
bi-weekly.
Site director will monitor clinical supervisors' accountability and progress in ensuring staff complete all required intake paperwork efficiently and according to regulations, policies, and procedures. |
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 review of client records and the policy and procedure manual, the facility failed to document a medical history, during the intake and admission process, in four of seven client records reviewed.The facility policy and procedure manual stated that the medical history will be completed within 45 working days of admission.Client #1 was admitted on August 18, 2022 and was discharged on January 30, 2023. There was no documentation of a medical history, in the record, at the time of the inspection.Client #5 was admitted on November 14, 2022 and was active at the time of inspection. The medical history was due no later than January 19, 2023; however, the history was completed on May 13, 2023.Client #6 was admitted on November 17, 2022 and was active at the time of inspection. The medical history was due no later than January 24, 2023; however, the history was completed on April 26, 2023.Client #7 was admitted on March 7, 2023 and was active at the time of inspection. The medical history was due no later than May 9, 2023; however, the history was completed on May 19, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to comply with Standard 709.91(b)(3)(i) Intake and Admission. According to agency policy and procedures, a medical history is required on all new admissions within 45 days. To avoid delayed completion of the medical history, completion of the medical history has reverted back to the behavioral health clinician to gather all regulatory medical system reviews within their scope of service.
GPHA's medical providers will no longer participate in capturing the required medical history and will only extend medical services based on referrals resulting from data gathered by the BH clinician, untreated medical conditions, or the clients request for medical services.
BH Clinical Staff will be retrained on June 30,2023 at 8:00 A.M. by the supervisor and director on completing medical histories.
Psychiatrists will also be retrained on how to submit their section without changing the date of the original biopsychosocial evaluation in order to preserve the original date completed.
Furthermore, urgent care specialist/receptionist will be given a refresher/training on the biopsychosocial evaluation policy with a focus on required data and due dates.
Each staffing category listed above will sign acknowledgement of training and review of the regulation and policy.
Follow up. Clinical coordinators/supervisors will review completed intakes on a weekly basis to ensure clinical soundness and scheduling of biopsychosocial evaluations within the required timeframe.
Follow up. The Clinical Supervisors will report findings to the Site Director during biweekly supervision, which will be relayed to Chief Behavioral Officer during biweekly BH leadership meetings.
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on review of client records and the policy and procedure manual, the facility failed to document a drug or alcohol history, during the intake and admission process, in four of seven client records reviewed.The facility policy and procedure manual stated that the drug or alcohol history will be completed within 45 working days of admission.Client #1 was admitted on August 18, 2022 and was discharged on January 30, 2023. There was no documentation of a drug or alcohol history, in the record, at the time of the inspection.Client #5 was admitted on November 14, 2022 and was active at the time of inspection. The drug or alcohol history was due no later than January 19, 2023; however, the history was completed on May 13, 2023.Client #6 was admitted on November 17, 2022 and was active at the time of inspection. The drug or alcohol history was due no later than January 24, 2023; however, the history was completed on April 26, 2023.Client #7 was admitted on March 7, 2023 and was active at the time of inspection. The drug or alcohol history was due no later than May 9, 2023; however, the history was completed on May 19, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to comply with Standard 709.91(b)(3)(ii) Intake and Admission. According to agency policy and procedures, a drug or alcohol history or both is required to be completed on all new admissions within 45 days.
BH Clinical Staff will be retrained on June 30,2023 at 8:00 A.M. by the supervisor and director on completing drug or alcohol history or both in the biopsychosocial evaluation document along with all other required fields and client history.
The training facilitators will reiterate that capturing alcohol and/or drug histories on other required forms does not remove or minimize the need to capture the drug and/or alcohol history on the biopsychosocial evaluation.
Psychiatrists will also be retrained on how to submit their section without changing the date of the original biopsychosocial evaluation in order to preserve the original date completed.
Furthermore, urgent care specialist/receptionist will be given a refresher/training on the biopsychosocial evaluation policy with a focus on required data and due dates.
Each staffing category listed above will sign acknowledgement of training and review of the regulation and policy.
Follow up. Clinical coordinators/supervisors will review completed intakes on a weekly basis to ensure clinical soundness and scheduling of biopsychosocial evaluations within the required timeframe.
Follow up. The Clinical Supervisors will report findings to the Site Director during biweekly supervision, which will be relayed to Chief Behavioral Officer during biweekly BH leadership meetings. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on review of client records and the policy and procedure manual, the facility failed to document a personal history, during the intake and admission process, in four of seven client records reviewed.The facility policy and procedure manual stated that the personal history will be completed within 45 working days of admission.Client #1 was admitted on August 18, 2022 and was discharged on January 30, 2023. There was no documentation of a personal history, in the record, at the time of the inspection.Client #5 was admitted on November 14, 2022 and was active at the time of inspection. The personal history was due no later than January 19, 2023; however, the history was completed on May 13, 2023.Client #6 was admitted on November 17, 2022 and was active at the time of inspection. The personal history was due no later than January 24, 2023; however, the history was completed on April 26, 2023.Client #7 was admitted on March 7, 2023 and was active at the time of inspection. The personal history was due no later than May 9, 2023; however, the history was completed on May 19, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to comply with Standard 709.91(b)(3)(iii) Intake and Admission. According to agency policy and procedures, a personal history is required to be completed on all new admissions within 45 days.
BH Clinical Staff will be retrained on June 30,2023 at 8:00 A.M. by the supervisor and director on completing a personal history in the biopsychosocial evaluation document along with all other required fields and client history.
Psychiatrists will also be retrained on how to submit their section without changing the date of the original biopsychosocial evaluation in order to preserve the original date completed.
Furthermore, urgent care specialist/receptionist will be given a refresher/training on the biopsychosocial evaluation policy with a focus on required data and due dates.
Each staffing category listed above will sign acknowledgement of training and review of the regulation and policy.
Follow up. Clinical coordinators/supervisors will review completed intakes on a weekly basis to ensure clinical soundness and scheduling of biopsychosocial evaluations within the required timeframe.
Follow up. The Clinical Supervisors will report findings to the Site Director during biweekly supervision, which will be relayed to Chief Behavioral Officer during biweekly BH leadership meetings. |
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 review of client records and the policy and procedure manual, the facility failed to document a psychosocial evaluation, during the intake and admission process, in five of six applicable client records reviewed.The facility policy and procedure manual stated that the psychosocial evaluation will be completed within 45 working days of admission.Client #1 was admitted on August 18, 2022 and was discharged on January 30, 2023. The psychosocial evaluation was due no later than October 15, 2022; however, the evaluation was completed on May 10, 2023.Client #2 was admitted on November 7, 2022 and was discharged on March 29, 2023. The psychosocial evaluation was due no later than January 10, 2023; however, the evaluation was completed on May 22, 2023.Client #5 was admitted on November 14, 2022 and was active at the time of inspection. The psychosocial evaluation was due no later than January 19, 2023; however, the evaluation was completed on May 22, 2023.Client #6 was admitted on November 17, 2022 and was active at the time of inspection. The psychosocial evaluation was due no later than January 24, 2023; however, the evaluation was completed on February 28, 2023.Client #7 was admitted on March 7, 2023 and was active at the time of inspection. There was no documentation of a psychosocial evaluation, in the record, at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to comply with Standard 709.91 (b)(6) Intake and Admission. According to agency policy and procedures, a Bio-Psychosocial evaluation is required to be completed on all new admissions within 45 days.
BH Clinical Staff will be retrained on June 30,2023 at 8:00 A.M. by the supervisor and director on completing the biopsychosocial evaluation document along with all other required fields and client history.
Psychiatrists will also be retrained on how to submit their section without changing the date of the original biopsychosocial evaluation in order to preserve the original date completed.
Furthermore, urgent care specialist/receptionist will be given a refresher/training on the biopsychosocial evaluation policy with a focus on required data and due dates.
Each staffing category listed above will sign acknowledgement of training and review of the regulation and policy.
Follow up. Clinical coordinators/supervisors will review completed intakes on a weekly basis to ensure clinical soundness and scheduling of biopsychosocial evaluations within the required timeframe.
Follow up. The Clinical Supervisors will report findings to the Site Director during biweekly supervision, which will be relayed to Chief Behavioral Officer during biweekly BH leadership meetings. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan, during the intake and admission process, in five of seven client records reviewed.Client #2 was admitted on November 7, 2022 and was discharged on March 29, 2023. There was no documentation of a preliminary treatment plan, in the record, at the time of the inspection.Client #4 was admitted on July 7, 2022 and was discharged on September 21, 2022. There was no documentation of a preliminary treatment plan, in the record, at the time of the inspection.Client #5 was admitted on November 14, 2022 and was active at the time of inspection. There was no documentation of a preliminary treatment plan, in the record, at the time of the inspection.Client #6 was admitted on November 17, 2022 and was active at the time of inspection. There was no documentation of a preliminary treatment plan, in the record, at the time of the inspection.Client #7 was admitted on March 7, 2023 and was active at the time of inspection. There was no documentation of a preliminary treatment plan, in the record, at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To comply with Standard 709.91 (b)(7) Intake and admission (b) Intake procedures shall include documentation of (7) Preliminary treatment and treatment and rehabilitation plan.
Along with the policy of GPHA to complete the initial Rehabilitation Plan within 15 working days from the date of admission. The following corrective action plan has been implemented to establish compliance moving forward in the initial treatment and rehabilitation plan.
Initial treatment and rehabilitation plans will be developed by the Drug and Alcohol Professional immediately following completion of the ASAM and Psychological Evaluation which occurs during the intake process.
A formal reoccurring weekly clinical supervisory team meeting has been established to review new intakes. This meeting will focus on reviewing all required intake documentation to ensure and establish compliance.
The programs clinical supervisory team shall review and verify each member's initial treatment plan prior to the 15th day following intake to ensure the plan has been completed and the appropriate approach to care is indicated on the initial treatment and rehabilitation plan. At this time, the initial treatment and rehabilitation plan will be finalized in the EHR system.
All new members shall be added to the DA Compliance Tracker during this meeting along with all upcoming updates for treatment and rehabilitation planning.
Members' signatures will not be required to finalize the document. However, an indication of the members' participation will be required along with an explanation in a progress note explaining why there is no signature.
Supervisors will discuss and review initial treatment and rehabilitation plans and updates during standard supervision as part of the supervision session.
The QA Department will monitor the Initial Rehabilitation Plan for compliance during weekly audits. Results from the findings will be shared during the monthly Director's Site Meeting and all staff meetings. Aggregated data from the findings will be reviewed during the BH Leadership Meeting to determine additional strategies for continued improvement.
Correction Time ? Completed
Monitoring ? Ongoing
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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
Based on a review of client records and the policy and procedure manual, the facility failed to develop and document the individual treatment and rehabilitation plan with the client in five of seven client records reviewed. The facility policy and procedure manual stated that the individual treatment and rehabilitation plan will be completed within 15 working days of admission.Client #1 was admitted on August 18, 2022 and was discharged on January 30, 2023. The treatment and rehabilitation plan was completed on August 22, 2022; however, there was no documentation that the treatment plan was developed with the client.Client #2 was admitted on November 7, 2022 and was discharged on March 29, 2023. The treatment and rehabilitation plan was due to be completed no later than November 28, 2022; however, the treatment plan was completed on May 22, 2023, after the client was discharged from treatment.Client #4 was admitted on July 7, 2022 and was discharged on September 21, 2022. The treatment and rehabilitation plan was due to be completed no later than July 28, 2022; however, the treatment plan was completed on May 23, 2023, after the client was discharged from treatment.Client #5 was admitted on November 14, 2022 and was active at the time of inspection. The treatment and rehabilitation plan was due to be completed no later than December 6, 2022; however, the treatment plan was completed on May 22, 2023.Client #6 was admitted on November 17, 2022 and was active at the time of inspection. The treatment and rehabilitation plan was due to be completed no later than December 12, 2022; however, the treatment plan was completed on February 28, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To comply with Standard 709.91 (b)(7) Intake and admission (b) Intake procedures shall include documentation of (7) Preliminary treatment and treatment and rehabilitation plan.
Along with the policy of GPHA to complete the initial Rehabilitation Plan within 15 working days from the date of admission. The following corrective action plan has been implemented to establish compliance moving forward in the initial treatment and rehabilitation plan.
Initial treatment and rehabilitation plans will be developed by the Drug and Alcohol Professional immediately following completion of the ASAM and Psychological Evaluation which occurs during the intake process.
A formal reoccurring weekly clinical supervisory team meeting has been established to review new intakes. This meeting will focus on reviewing all required intake documentation to ensure and establish compliance.
The programs clinical supervisory team shall review and verify each member's initial treatment plan prior to the 15th day following intake to ensure the plan has been completed and the appropriate approach to care is indicated on the initial treatment and rehabilitation plan. At this time, the initial treatment and rehabilitation plan will be finalized in the EHR system.
All new members shall be added to the DA Compliance Tracker during this meeting along with all upcoming updates for treatment and rehabilitation planning.
Members' signatures will not be required to finalize the document. However, an indication of the members' participation will be required along with an explanation in a progress note explaining why there is no signature.
Supervisors will discuss and review initial treatment and rehabilitation plans and updates during standard supervision as part of the supervision session.
The QA Department will monitor the Initial Rehabilitation Plan for compliance during weekly audits. Results from the findings will be shared during the monthly Director's Site Meeting and all staff meetings. Aggregated data from the findings will be reviewed during the BH Leadership Meeting to determine additional strategies for continued improvement.
Correction Time ? Completed
Monitoring ? Ongoing
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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
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of four applicable client records reviewed.Client #1 was admitted on August 18, 2022 and was discharged on January 30, 2023. The individual treatment and rehabilitation plan was completed on August 22, 2022, and the first update was due no later than October 22, 2022; however, the update was completed on November 21, 2022.Client #3 was admitted on August 24, 2022 and was discharged on November 4, 2022. The individual treatment and rehabilitation plan was completed on August 24, 2022, and the first update was due no later than October 24, 2022; however, the update was not completed prior to discharge.Client #6 was admitted on November 17, 2022 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on February 28, 2023, and the first update was due no later than April 28, 2023; however, the update was completed on May 22, 2023.This is a repeat citation from the June 1, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to comply with Standard 709.92(b) Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
Clinical Supervisors will monitor the DA Compliance Tracker weekly to identify Members with Treatment and Rehabilitation Plans that are approaching the 60-day review date and coordinate the due date in advance with the Counselor and Member.
Treatment and Rehabilitation Plans for Drug and Alcohol members will no longer be driven by regularly scheduled appointments but developed and processed based on the treatment and rehabilitation plan update due date. All efforts will be made to coordinate with the members in advance to obtain input and signatures.
Treatment and Rehabilitation Updates will be finalized electronically every 60-days providing day 60 falls on a workday. In the event of day 60 falling outside of a scheduled workday, the Treatment and Rehabilitation Plan will be finalized within 24 hours of the scheduled Treatment and Rehabilitation Plan Update due date.
An addendum to information in the Treatment and Rehabilitation Plans may occur after the finalized Treatment and Rehabilitation Plan Update at the request of the Member, Counselor, or Clinical Supervisory Team.
Information regarding Treatment and Rehabilitation Plan Addendum and Finalization Process will be added to the Treatment and Rehabilitation Plan Policy and reviewed with the Policy and Procedure Sub-Committee on Friday, July 7, 2023.
ALL Clinical Staff will receive a copy of the revised policy with the revisions highlighted on Monday, July 10, 2023. Formal training of the revision will take place on July 18, 2023. In the meantime, the changes and expectations will take place during supervision sessions.
On-going Monitoring:
Supervisors will monitor treatment and rehabilitation plans weekly using the DA tracker to identify upcoming Treatment and Rehabilitation Plans that are due for a 60-day Update until the member has satisfied the requirements for program discharge.
The QA Department will continue to reconcile the treatment and rehabilitation plan audits weekly to identify treatment plan update completion and those in need of completion based on scheduled appointments.
The Site Director will be responsible for weekly monitoring of the Clinical Supervisors compliance with tracking DA services and to ensure that quality services are being provided based on the level of care and treatment outlined in the treatment and rehabilitation plan.
The QA Manager will audit treatment and rehabilitation plans for compliance with 709.92 (b) and for clinical soundness. Aggregate findings per location, per supervisor, per counselor will be reported to the BH Leadership Team Monthly and Quarterly to the Executive Staff. The purpose of pulling aggregate data on each site and employees is to identify gaps in care and to identify if additional training is need on a site level or individual level.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in three of four applicable client records reviewed. Client #3 was admitted on August 24, 2022 and was discharged on November 4, 2022. The individual treatment and rehabilitation plan was completed on August 24, 2022 and indicated bi-weekly individual therapy sessions. There was no documentation, in the record, of individual sessions occurring during the month of September 2022. Client #6 was admitted on November 17, 2022 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on February 28, 2023 and indicated bi-weekly individual therapy sessions. There was no documentation, in the record, of individual sessions occurring during the months of March 2023 and April 2023.Client #7 was admitted on March 7, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on March 7, 2023 and indicated monthly individual therapy sessions. There was no documentation, in the record, of an individual session occurring during the month of April 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92(c) LICENSURE
Treatment and rehabilitation services:
709.92. Treatment and rehabilitation services. (c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
To comply with 709.92. (c) Treatment and rehabilitation services, the following measures have been put in place to ensure that counseling services are provided according to the individual treatment and rehabilitation plan.
Clinical Supervisors will ensure that frequency of individual and group sessions are added to the DA tracker to monitor treatment scheduling compliance based on the proposed treatment frequency. The clinical supervisor will monitor the DA Tracker weekly to ensure compliance of treatment frequency.
Clinical Counselors who fail to schedule according to the proposed treatment frequency will be reminded immediately of the need to schedule appointments as outlined in the approved treatment and rehabilitation plan.
Members who are scheduled according to the proposed treatment frequency and fail to attend the scheduled treatment session will receive follow-up to identify the causal factor(s) for the missed appointment and to reschedule the missed appointment. If the member continues to miss scheduled appointment despite efforts to encourage full treatment participation, an addendum to the treatment and rehabilitation plan will be made to align with the Members current ability to actively participate in treatment.
On-going Monitoring:
Supervisors will monitor treatment and rehabilitation plan (treatment frequency) weekly using the DA tracker to identify scheduling and participation compliance with Treatment and Rehabilitation Plan identified treatment frequency.
The Site Director will be responsible for weekly monitoring of the Clinical Supervisors compliance with tracking DA services and to ensure that quality services are being provided based on the level of care, treatment frequency, and treatment outlined in the treatment and rehabilitation plan.
The Site Director will be responsible for reporting on the findings of the DA Tracker in monthly site meetings. Aggregate findings will be reported to identify gaps in care and to identify if additional training is needed on a site level or individual level.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records and the policy and procedure manual, the facility failed to document a complete client record, which is to include case consultation notes, in four of four applicable client records reviewed.The facility policy and procedure manual stated that case consultations will be completed every 90 days.Client #1 was admitted on August 18, 2022 and was discharged on January 30, 2023. The case consultation was due no later than November 18, 2022; however, the case consult was completed on May 10, 2023.Client #2 was admitted on November 7, 2022 and was discharged on March 29, 2023. The case consultation was due no later than January 7, 2023; however, the case consult was completed on May 22, 2023.Client #5 was admitted on November 14, 2022 and was active at the time of inspection. The case consultation was due no later February 14, 2023; however, the case consults were completed on May 4, 2023 and May 22, 2023.Client #6 was admitted on November 17, 2022 and was active at the time of inspection. The case consultation was due no later than February 17, 2022; however, the case consult was completed on May 10, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.93 LICENSURE Client Records:
In an effort to reestablish and maintain compliance as it relates to standard 709.93 (a) (8), the following corrective action plan has been revitalized and updated considering staff turnover, hybrid employees, and new hires.
Effective July 10, 2023, Case
Consultations will be scheduled weekly to ensure timely completion and presenting capacity of Case Consultations both in person and via secure zoom meeting room.
A targeted case consultation session is scheduled for July 18th, 2023 with Counselors for active Client Charts that were out of compliance during the audit.
An in-service review of the Case Consultation policy and standard 709.93 (a) (8), has been added to the scheduled in service for July 21st, 2023. During this in-service staff will be given a pre-posttest of the regulations and policy. Training emphasis 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 Consultation and Obtaining Signatures of Participants.
Monitoring On-going
Case consultations are identified on the DA Tracker and is the responsibility of the Clinical Supervisor to ensure compliance with 709.93 (a) (8).
Clinical Supervisor are responsible for knowing when a case consultation is due and obligated to ensure that Counselors are completing and presenting Case Consultations in a timely manner.
The Site Director is responsible for monitoring this process and reporting the final results to the BH Leadership Team during monthly Meetings. Moving forward the Site Director will Monitor Compliance weekly and consult with the Clinical Supervisor to ensure Case Consultation are meeting compliance prior to the monthly report/
The QA Manager will monitor and report on Case Consultation Compliance during the Monthly Site Meeting based on Key Performance Indicators in the EHR system.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records and the policy and procedure manual, the facility failed to document a complete client record, which is to include a discharge summary, in four of four applicable client records reviewed.The facility policy and procedure manual stated that discharge summary will be completed within 7 days of discharge.Client #1 was admitted on August 18, 2022 and was discharged on January 30, 2023. The discharge summary was due no later than February 6, 2023; however, the summary was completed on May 22, 2023.Client #2 was admitted on November 7, 2022 and was discharged on March 29, 2023. The discharge summary was due no later than April 5, 2023; however, the summary was completed on May 22, 2023.Client #3 was admitted on August 24, 2022 and was discharged on November 4, 2022. The discharge summary was due no later than November 11, 2022; however, the summary was completed on January 19, 2023.Client #4 was admitted on July 21, 2022 and was discharged on September 21, 2022. The discharge summary was due no later than September 28, 2022; however, the summary was completed on October 13, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to comply with 709.93(a)(10) Discharge summary. The following corrective action plan has been revitalized and updated considering staff turnover, hybrid employees, and new hires.
Effective July 10, 2023, the Admissions and Discharge Dept. "AD Dept." will generate and monitor last date of service reports daily to ensure members loss to care are discharged on day 30 and/or at the end of business day Friday-if member's date of discharge falls on the weekend.
AD Dept. will initiate discharge and discharge notation for members identified out-of-compliance and notify Clinical Supervisors in writing that a written discharge summary and supporting fields is needed for members who participated in services more than three (3) times with an identified Counselor. AD Dept. will initiate and complete discharge in its entirety for members who failed to complete the intake process and/or return after the intake process.
Monitoring On-going
Discharged Members are identified on the DA Post-Discharge Tracker. AD Dept. will update and maintain tracker daily based on generated Key Performance reports in the EHR system. AD Manager will monitor Clinical Supervisors and Counselor to ensure discharge summary is completed within seven (7) days of notification.
Clinical Supervisors will instruct Counselor to complete discharge summary and required fields no later than day seven (7) post-discharge. Upon completion, AD Dept. will update Post-Discharge Tracker to identify clinicians' compliance per regulations.
Clinical Supervisors are responsible for notifying Counselor when an discharge summary is due and obligated to ensure that Counselors are completing discharge summary and supporting fields in a timely manner.
The AD Manager is responsible for monitoring this process and reporting the final results to the BH Leadership Team during monthly Meetings. Moving forward the AD Manager will Monitor Compliance weekly and consult with the Site Director and Clinical Supervisor to ensure discharge summary are meeting compliance prior to the monthly report.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records and the policy and procedure manual, the facility failed to document a complete client record, which is to include follow-up information, in three of three applicable client records reviewed.The facility policy and procedure manual stated that follow-up will be completed no less than 30 days and no more than 90 days. Client #1 was admitted on August 18, 2022 and was discharged on January 30, 2023. The follow-up information was due no later than April 30, 2023; however, follow-up was documented on May 22, 2023.Client #3 was admitted on August 24, 2022 and was discharged on November 4, 2022. The follow-up information was due no later than February 4, 2023; however, follow-up was documented on May 23, 2023.Client #4 was admitted on July 21, 2022 and was discharged on September 21, 2022. The follow-up information was due no later than December 21, 2022; however, follow-up was documented on May 23, 2023.This is a repeat citation from the February 9, 2021, June 16-17, 2021, and June 1, 2022 annual licensing renewal inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to comply with 709.93(a)(11) Follow-Up information. The following corrective action plan has been revitalized and updated considering staff turnover, hybrid employees, and new hires.
Effective July 10, 2023. The agency will implement a new post-discharge tracking model to capture and monitor members discharged from care to ensure timely completion of aftercare follow-up.
A targeted aftercare follow-up session is scheduled for July 17, 2023 with Clinicians and Site Directors to review in-active and recently discharged members.
An in-service review of follow-up to care policy and standard 709.93 (a) (11), has been added to the scheduled in-service for July 18th, 2023. During this in-service staff will be given a pre-posttest of the regulations and policy. Training emphasis will be placed on the following: The Purpose of Conducting Aftercare Follow-up, Timelines, Electronic Form Completion, Recording the outcome of follow-up.
Monitoring On-going
Discharge members are identified on the DA Post-Discharge Tracker and is the responsibility of the Clinical Supervisor to ensure compliance with 709.93 (a) (11). Clinical Supervisor are responsible for knowing when an aftercare follow-up is due and obligated to ensure that Counselors are completing and documenting follow-up to care in a timely manner.
The Site Director is responsible for monitoring this process and reporting the final results to the BH Leadership Team during monthly Meetings. Moving forward the Site Director will Monitor Compliance weekly and consult with the Clinical Supervisor to ensure follow-up to care are meeting compliance prior to the monthly report.
The AD Manager will monitor and report on Follow-up to Care Compliance during the Monthly Site Meeting based on Key Performance Indicators in the EHR system.
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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. Plans of corrections for not documenting follow-up information were submitted and approved by the Department for the February 9. 2021, June 16-17, 2021, and June 1, 2022 annual licensing inspections. Not documenting follow-up information was again found to be a deficiency in the May 23, 2023, licensing inspection.This is a repeat citation from the June 1, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
709.17. Refusal or revocation of license. (3) Failure to comply with a plan of correction approved by the Department.
We have identified corrective actions based on the results of the deficiencies outlined during our recent site audit. Each corrective action is specific, measurable, achievable, relevant, and time bound. Policy changes were made to establish a timeline that is more realistic, manageable and demonstrates our commitment to resolving the identified issues promptly.
We have allocated the necessary resources required to implement the corrective action plans efficiently and effectively. This includes additional staffing, staff training, EHR upgrades, updated policies, and procedures to bring the program into compliance.
- Additional staff training and education: we will provide comprehensive training and education to the staff members by August 25, 2023, to ensure they understand and comply with the specific requirements outlined in the Pennsylvania Codes that govern Outpatient Drug and Alcohol Programs. This will include training on documentation practices, treatment protocols, safety protocols, ethical guidelines, or any other relevant areas.
We will implement by September 15, 2023, a more robust quality assurance process to monitor ongoing compliance with the codes and ensure that corrective actions are effective. This will involve regular audits, internal reviews, and a system for addressing any identified deficiencies promptly. It will also include conducting a standard weekly group meeting with the Counselor III to discuss Client care and treatment protocols.
We will implement a comprehensive documentation system to track and record all corrective actions, staff training, policy updates, quality assurance training, policy update, quality assurance activities, and any other relevant information by September 15, 2023. This documentation will be crucial in monitoring and demonstrating the program's compliance.
Our goal is to establish compliance and continuous improvement. We are committed to an ongoing process for continuous improvement to identify areas for enhancement and implement necessary changes to maintain and eventually exceed the requirements outlined in Pennsylvania's code.
Timeline for establishing the goals September 15, 2023
Ongoing Monitoring
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