INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 18, 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 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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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's August 2023 through June 2024 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.
There were eleven fire drills completed during the reviewed period. One fire drill was conducted at 3:00PM and the rest were conducted prior to 12:30PM. The facility's posted hours of operation are Monday, Wednesday, Friday from 8:30AM to 5:00PM and Tuesday, Thursday from 8:30AM to 8:00PM. None of the fire drills were conducted during the Tuesday and/or Thursday evening hours of operation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
705.28 (d) (6) LICENSURE
Fire safety.:
705.28. Fire safety. (d) Fire drills. The nonresidential facility shall: (6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
In order to comply with standard 705.28(d(6)) on fire safety and fire drills being conducted on different days of the week, at other times of the day, and on various shifts, the following corrective action has been implemented:
A fire drill tracking form was developed to ensure fire drills are conducted during all shifts. Safety and Security Officers were trained on the fire drill tracker on July 26, 2024. The Safety and Security Officers were instructed to review the tracking form before performing the next fire drill to determine the day, date, and time of prior drills this calendar year to avoid date, day, or time patterns moving forward. The Safety and Security Officers must strategically plan fire and other safety drills to ensure various drills are placed during all shifts.
Safety and Security Officers are instructed to discuss only the pending monthly drill with the QA manager to ensure they comply with 705.28 (d)(6) before facilitating the drills.
The Quality Assurance Manager will monitor and track fire drill compliance monthly. The QA Manager will present the fire drill tracking form during site leadership meetings and provide the BH leadership with a quarterly summary of the fire drill report. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #4 was admitted on September 28, 2023 and was discharged on January 5, 2024. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.28 (c) LICENSURE
Confidentiality:
§ 709.28. Confidentiality. (c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
To comply with § 709.28 (c) Confidentiality. An in-depth audit was conducted to determine the root cause of this infraction. Once the causal factors were identified, a full audit of all new members registered by the employee was conducted to determine if this infraction was widespread or limited. As a result of the findings, the employee was personally retrained on July 29, 2024, on regulation 709.28 Confidentiality, emphasizing (c).
Additionally, on July 20, 2024, the audit findings were shared and discussed in detail during the monthly Registration Assistant meeting.
In addition, the Member Registration Completion Requirement policy was revised to state that no new member should be rushed through the registration process, Counselors must wait until the registration process is complete, Members who decline to voluntarily sign a consent form to release information to their insurance company for payment will need to enter into a self-payment agreement and must pay for services in advance of treatment, and the Client Service Coordinator or Lead Registration Assistant, in the absence of the Client Service Coordinator must review the registration of new members upon completion to ensure compliance with § 709.28 before the member departs registration. The revised policy will be presented to the policy committee on August 13, 2024.
Ongoing monitoring: DA clinical Supervisors/Coordinators will monitor active Clients to ensure all informed and voluntary consent forms comply with § 709.28. The Admission and Discharge Manager will perform bi-weekly audits of new admits, ensuring that the informed and voluntary consent forms are completed according to standards. The admission and discharge manager will present findings from the audit quarterly to the BH Leadership Team. |
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, the facility failed to maintain a complete client record on an individual, which is to include follow-up information, in four of four applicable client records reviewed.
Client #4 was admitted September 28, 2023 and was discharged on January 5, 2024. There was no documentation of follow-up information in the record at the time of inspection.
Client #5 was admitted September 26, 2023 and was discharged on February 25, 2024. There was no documentation of follow-up information in the record at the time of inspection.
Client #6 was admitted December 15, 2023 and was discharged on April 11, 2024. There was no documentation of follow-up information in the record at the time of inspection.
Client #7 was admitted November 16, 2023 and was discharged on February 28, 2024. There was no documentation of follow-up information in the record at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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.
To comply with 709.93(a)(11) Follow-Up information. The following corrective action plan has been implemented.
The agency has added and implemented a new pre-discharge tracking model to capture and monitor Members' appointment non-compliance to ensure timely completion of follow-up to care after missed appointments that could potentially lead to an administrative discharge.
The follow-up to care form will be used to document all follow-up efforts. Additionally, written follow-up notifications will be sent to the Member's email address through the patient portal and tracked on the follow-up form. At a minimum, Primary counselors will be required to complete four follow-ups to care efforts to reengage the Member before administratively discharging a Member from care for non-compliance. Once the Member is administratively discharged from care for non-compliance, Counselors will not be required to make additional follow-up efforts.
Regulation 709.93 (a) (11) and the procedures for follow-up will be reviewed with staff on Friday, August 16, 2024, during the in-service training. During this in-service training, staff will be given a copy of the regulations and follow-up policy. Training emphasis will be placed on the following: the purpose of Conducting Follow-up, Timelines, Electronic Form Completion, Recording the outcome of follow-up, and Utilizing the Patient Portal as a Follow-up to Care Strategy.
Monitoring On-going
Clinical Supervisors are required to monitor no-shows and to ensure that follow-up care for missed appointments is occurring and documented on the day of the missed appointment to ensure compliance with 709.93 (a) (11).
Clinical Supervisors are responsible for reviewing the clinical chart before signing off on an administrative discharge to ensure that counselors complete follow-up efforts to reengage the Member in treatment.
Clinical Supervisors are responsible for monitoring pending discharge Members and discussing those cases during clinical supervision to ensure compliance.
The Site Director monitors this process and reports the final results to the BH Leadership Team during monthly Meetings. The Site Director will Monitor compliance weekly and consult with the Clinical Supervisor to ensure follow-up care meets compliance before the monthly report.
The AD Manager will monitor and report on follow-ups to care compliance during the monthly site meeting based on key performance indicators in the EHR system. |