INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 19-21, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, 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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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to document the clients' medical, drug and alcohol, and/or personal history as stated in agency policy in three of seven client records.The findings include:The policy referring to the comprehensive biopsychosocial assessment, which includes the medical, drug and/or alcohol, and personal histories stated that the comprehensive biopsychosocial assessment is to be completed within fifteen working days. Seven client records requiring documentation of histories were reviewed on August 20-21, 2013. The facility failed to document all or components of the client histories in client records # 1, 4, and 7.Client #1 was admitted to treatment on February 6, 2013. As of the date of inspection, there was no documentation of a drug and alcohol history for client #1. Client #4 was admitted to treatment on January 28, 2013 and discharged on July 15, 2013. As of the date of inspection, there was no documentation of a medical, drug and alcohol, or personal history for client # 4. Client #7 was admitted to treatment on November 28, 2012 and discharged on June 24, 2013. As of the date of inspection, there was no documentation of a medical, drug and alcohol, or personal history for client # 7. The findings were reviewed with quality assurance staff, the clinical director, and the facility director during the exit interview.
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Plan of Correction
709.91
INTAKE and ADMISSION
Based on a review of client records, the facility failed to document the client's medical, drug/alcohol and/or personal history in three of seven records.
CORRECTIVE ACTION
The 2013 DDAP Licensing Renewal Inspection findings will be disseminated and reviewed with the Coordinators in the next scheduled Management Meeting. The Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will conduct a training with Drug/Alcohol Counselors to cover the following areas:
- time frame for completing the Comprehensive Bio-Psychosocial History (CBE).
- instructions for completing the medical history section of the CBE.
- instructions for completing the drug/alcohol history section of the CBE.
- instructions for completing the personal history section of the CBE.
- required areas to be assessed/evaluated when completing the CBE.
- strategies for ensuring that CBE's are evaluative, and include the counselor's conclusions/impressions.
Additionally, the Drug/Alcohol Clinical Coordinator and Quality Assurance Clerks will monitor client records weekly to ensure that all Bio-Psychosocial Histories are completed in accordance with GPHA, Inc's policies/procedures, and DDAP regulations. All newly hired clinical staff will also receive this training during their orientation period.
TIME FRAME FOR COMPLETION
October 15, 2013 -Combined Training / Ongoing Monitoring
PERSONS RESPONSIBLE
Drug /Alcohol Clinical Coordinator, Quality Assurance Coordinator, Coordinator of Behavioral Health Services
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on the review of client records, the facility failed to document the clients' consent to treatment in two of seven client records.The findings include:Consent to drug and alcohol treatment must be signed by the client prior to the start of treatment. Seven client records requiring documentation of consent to treatment were reviewed on August 20, 2013. The facility failed to document consent to treatment in client records # 4 and 5.Client #4 was admitted to treatment on January 28, 2013 and discharged on July 15, 2013. As of the date of inspection, there was no documentation of consent to drug and alcohol treatment for client # 4. Client #5 was admitted to treatment on February 15, 2013 and discharged on June 3, 2013. As of the date of inspection, there was no documentation of consent to drug and alcohol treatment for client # 5. The findings were reviewed with quality assurance staff, the clinical director, and the facility director during the exit interview.
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Plan of Correction
709.91(b)(4)
INTAKE and ADMISSION
Based on a review of client's records, the facility failed to document the client's consent to treatment in two of seven records.
CORRECTIVE ACTION
The 2013 DDAP Licensure Renewal Inspection findings will be disseminated and reviewed with Coordinators in the next scheduled Management Meeting. The Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will conduct a training with Urgent Care Specialist and Counselors to include the following training areas:
- review of GPHA. Inc's policy/procedures on Consent to Treatment documentation.
- process for completing and signing Consent to Treatment forms during intake.
Urgent Care Specialists' supervisors (Clinical Coordinators) will review intake documents daily, and in weekly supervision sessions to ensure that a signed Consent to Treatment form is included in all client intake records. All newly hired clinical staff will receive this same training during their orientation period.
TIME FRAME FOR COMPLETION
October 15, 2013 - Combined Training / Ongoing Monitoring
PERSONS RESPONSIBLE
Drug/Alcohol Clinical Coordinator, Quality Assurance Coordinator, Coordinator of Behavioral Health Services.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document the clients' psychosocial assessment as stated in agency policy in three of seven client records.The findings include:The policy referring to the comprehensive biopsychosocial assessment, which includes the psychosocial evaluation states: Part 2 of the comprehensive biopsychosocial assessment is to be completed within thirty working days. Seven client records requiring documentation of a psychosocial evaluation were reviewed on August 20-21, 2013. The facility failed to document psychosocial evaluations in client records # 4, 5, and 7.Client #4 was admitted to treatment on January 28, 2013 and discharged on July 15, 2013. As of the date of inspection, there was no documentation of a psychosocial evaluation for client # 4. Client #5 was admitted to treatment on February 15, 2013 and discharged on June 3, 2013. As of the date of inspection, there was no documentation of psychosocial evaluation for client # 5. Client #7 was admitted to treatment on November 28, 2012 and discharged on June 24, 2013. As of the date of inspection, there was no documentation of a psychosocial evaluation for client # 7. The findings were reviewed with quality assurance staff, the clinical director, and the facility director during the exit interview.
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Plan of Correction
709.91(b)(6) INTAKE and ADMISSION
Based on a review of client records, the facility failed to document the client's psychosocial evaluation (Part 2 of the Comprehensive Bio-Psychosocial Evaluation), as stated in the agency policy, in three of seven client records.
CORRECTIVE ACTION
The 2013 DDAP Licensure Renewal Inspection findings will be disseminated and reviewed with Clinical Coordinators in the next scheduled Management Meeting. The Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will conduct a training for Drug/Alcohol Counselors to cover the following areas:
- GPHA, Inc's policy and procedures on Comprehensive Bio-Psychosocial (CBE).
- time frame for completing the Comprehensive Bio-Psychosocial Evaluation (Clinical Impression).
- required areas to be assessed and evaluated when completing the CBE.
- strategies for ensuring that the CBE is evaluative, and includes the Counselor's conclusions/impressions.
The Clinical Coordinator and Quality Assurance Clerks will monitor client's records weekly to ensure that Clinical Impressions are completed in accordance with GPHA, Inc's policy/procedures, and DDAP regulations. All newly hired clinical staff will receive this training during their orientation period.
TIME FRAME FOR COMPLETION
October 15, 2013 - Combined Training / Ongoing Monitoring
PERSONS RESPONSIBLE
Drug/Alcohol Clinical Coordinator, Quality Assurance Coordinator, Coordinator of Behavioral Health
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include the type and frequency of treatment and rehabilitation services in three out of seven client records. The findings include:Seven client records were reviewed for treatment plans on August 20-21, 2013. Three out of seven client records lacked documentation of a treatment plan that included the type and frequency of treatment and rehabilitation services, specifically client records # 1,3, and 5. The treatment plan for client # 1 was completed on April 18, 2013 and did not include the type and frequency of treatment and rehabilitation services.The treatment plan for client # 3 was completed on June 28, 2013 and did not include the type and frequency of treatment and rehabilitation services.The treatment plan for client # 5 was completed on February, 22, 2013 and did not include the type and frequency of treatment and rehabilitation services.The findings were reviewed with quality assurance staff, the clinical director, and the facility director during the exit interview.
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Plan of Correction
709.92(a)(2) TREATMENT and REHABILITATION
Based on a review of client records, the facility failed to document treatment plans to include the frequency and type of treatment and rehabilitation services, in three of seven client records.
CORRECTIVE ACTION
The 2013 DDAP Licensure Renewal Inspection findings will be disseminated and reviewed with Clinical Coordinators in the next scheduled Management Meeting. The Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will conduct a training for Drug/Alcohol Counselors to include the following training areas:
- time frame for completion of comprehensive treatment plans and treatment plan updates.
- instructions for documenting the types and frequency of treatment and rehabilitation services in treatment plans.
- instructions for developing clear and measurable goals and objectives in treatment plans.
The Drug/Alcohol Clinical Coordinator and Quality Assurance Clerks will conduct weekly record reviews to ensure that all client treatment plans include types and frequency of treatment/rehabilitation services.
TIME FRAME FOR COMPLETION
October 15, 2013 - Combined Training / Ongoing Monitoring
PERSONS RESPOSIBLE
Drug/Alcohol Clinical Coordinator, Quality Assurance Coordinator, Coordinator of Behavioral Health Services.
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include proposed support services in five out of seven client records. The findings include:Seven client records were reviewed for treatment plans on August 20-21, 2013. Five out of seven client records lacked documentation of a treatment plan that included proposed support services, specifically client records # 1, 2, 5, 6, and 7. The treatment plan for client # 1 was completed on April 18, 2013 and did not include proposed support services.The treatment plan for client # 2 was completed on April 15, 2013 and did not include proposed support services.The treatment plan for client # 5 was completed on February 22, 2013 and did not include proposed support services.The treatment plan for client # 6 was completed on June 14, 2013 and did not include proposed support services.The treatment plan for client # 7 was completed on February 6, 2013 and did not include proposed support services.The findings were reviewed with quality assurance staff, the clinical director, and the facility director during the exit interview.
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Plan of Correction
709.92(a)(3) TREATMENT and REHABILITATION
Based on a review of the client's records, the facility failed to document treatment plans to include proposed support services in five of seven client records.
CORRECTIVE ACTION
The Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will conduct a training for Drug/Alcohol Counselors to cover the following areas:
- the importance of client support services in recovery from substance abuse/addiction.
- instructions for assessing and identifying relevant support services for clients.
- instructions for incorporating client support services in treatment planning.
- listing of client support service resources within the community.
The Drug/Alcohol Clinical Coordinator and Quality Assurance Clerks will monitor client records weekly to ensure that all treatment plans include relevant client support services. All newly hired clinical staff will receive this training during their orientation period.
TIME FRAME FOR COMPLETION
October 15, 2013 - Combined Training / Ongoing Monitoring
PERSONS RESPONSIBLE
Drug/Alcohol Clinical Coordinator, Quality Assurance Coordinator, Coordinator of Behavioral Health Services.
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