INITIAL COMMENTS
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This report is a result of an on-site follow-up inspection conducted on February 2, 2024 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on an administrative review, the facility failed to present the completed plan documenting the qualifications and training of staff to the Department licensing representatives at the time of the project's site visit. The facility was unable to produce a fully completed and signed Staffing Requirements Facility Summary Report documenting the qualifications and trainings of staff after multiple attempts at technical assistance by the Department licensing representative.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
704.2(b) Staffing Plan. 704.2 Compliance plan. (b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
The Facility failed to fully complete and sign the staffing requirements facility summary report at the time of the unannounced site visit. The staffing requirements facility summary report will be updated at minimum quarterly in preparation for audits by the CBHO. In preparation for competing priorities, the site supervisor has been giving the authority and will be trained on retrieving data from ADP and GPHA's University to facilitate the responsibility of completing, validating, and signing the staffing requirement facility summary report during an unannounced visit. Training is scheduled for March 29, 2024.
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709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to maintain a recordkeeping system that allowed for the identification of clients' admission and discharge dates within a specific time period. Upon the Licensing Representative's arrival, the facility provided a spreadsheet with very few active clients on it. The facility failed to provide a complete active list from the requested time period of August 2023 through the date of the inspection. Additionally, there was no list of discharged clients within the same time period provided to the Licensing Representative. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
709.31. Data collection system. (b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
The Clinical Supervisor has received full access to run and pull reports independent of a request submission to the IT department or site director. The Clinical Supervisor will be trained to run Admissions and Discharge reports from Avatar's KPI. Training is scheduled for March 29, 2024. Upon completion of the report training. Clinical supervisors will be required to run monthly reports to maintain the learned skills. Additionally clinical supervisors will be required to provide Admissions and Discharge reports during monthly leadership meetings.
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709.15(b) LICENSURE Subchapter B.Licensing Procedures.Right to en
709.15. Right to enter and inspect.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
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Observations
Based on a review of client records, the facility failed to provide full and free access to the records of the facility and its clients.During the inspection, the facility utilizes an electronic client record system and did not grant all the electronic permissions needed for the Licensing Representative to have full access to all current and discharged clients identified for the inspection review period. The facility did provide an auditor's access; however, there were no client record-related documents in this access view. Additionally, upon a request to correct the issue, the facility did not make the corrections within the on-site inspection timeframe. All the client records reviewed were done so through a third-party application with the clinical supervisor. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
709.15(b) Subchapter B. Licensing Procedures. Right to enter and inspect. (b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
Within a few weeks of this unannounced site visit, the facility had transitioned from one EHR platform to another EHR platform from the same vendor. The approved standard free access auditing rights and visibility was granted to the auditors as in previous years. Unfortunately, the auditor's rights previously used did not provide the same free access visibility as previously shown. We are still in the implementation phase. We are still striving to obtain fluent navigation of the new system. We are testing access with our EHR vendor. We are placing support tickets with our EHR vendor as we are discovery infractions from our transition. We are in the process of ensuring that free access to the facility records is reestablished under the auditor's view. Effective April 3, 2024, we will officially close the implementation phase. The authorized Department representative shall have full and free access to the records of the facility and its clients during all site visits without fail by April 3, 2024.
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