INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 16, 2021 through June 17, 2021 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in one of three applicable client records. Client #1 was admitted on March 8, 2021 and was active at the time of inspection. The policy and procedure manual stated that the comprehensive treatment plan was to be completed within 15 working days of admission; however, the comprehensive treatment plan was completed on April 12, 2021. Additionally, the policy and procedure manual stated that the biopsychosocial histories are to be completed within 30 working days of admission; however, the biopsychosocial history was completed on May 21, 2021.This is a repeat citation from the February 9, 2021 licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Standard in Non-Compliance
709.24 (a)(3) Treatment and Rehabilitation Management
On February 15, 2021, GPHA Al-Assist Behavioral Health Care Center revised its Treatment and Rehabilitation Planning policy. The revised policy went into effect on March 19, 2021. The agency no longer refer to the Treatment and Rehabilitation Plan as a Comprehensive Treatment Plan or require that a Comprehensive Treatment Plan to be developed within 15-working days after the initial/preliminary plan. The revised policy follows the language of Standard 709.24 (a) (3).
A copy of the revised Treatment and Rehabilitation Planning Policy was sent to DDAP.
In an effort to meet the standards of 709.24 (a) (3) the facility has put the following measures in place. The Drug and Alcohol Committee implemented the use of a compliance tracker to monitor treatment and rehabilitation planning, completion of the biopsychosocial evaluation, along with other compliance standards for all active cases.
The tracker is reviewed by the Clinical Supervisor, the Counselor IIIs and the Drug & Alcohol Committee on a weekly basis for compliance.
The results of this site visit was presented to the Drug and Alcohol Committee on July 21, 2021. The committee members discussed further strategies to ensure compliance with the current Treatment and Rehabilitation Planning Policy. The Clinical Coordinators will monitor the tracker from time of admission to ensure that a Treatment and Rehabilitation Plan Update is completed 60-days from the date of the initial plan.
And,
The clinical coordinator and admission and discharge manager will monitor the drug and alcohol tracker to ensure that the biopsychosocial history has been captured in its entirety and a summary of the data gathered is completed within 30-days of admission.
On-going Monitoring: The Site Director is responsible for providing on-going feedback regarding treatment and rehabilitation management during morning check-in, monthly staff meetings and supervisions.
Clinical Coordinators will review and discuss during supervision all new admit cases with the primary counselor to ensure compliance.
QA Department will monitor compliance prior and within 24-hours after all scheduled visits. Reports of all findings is provided to Counselor IIIs, Clinical Coordinators and Clinical Supervisors in an effort to ensure compliance at time of visit.
The DA Committee will review all reports to measure compliance and further develop strategies to ensure overall compliance with new admits and established clients.
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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 a review of client records, the facility failed to document, during the intake and admission process, a completed psychosocial evaluation in one of three applicable client records.Client #1 was admitted on March 8, 2021 and was active at the time of inspection. There was no psychosocial evaluation documented as of the date of the inspection. These findings was reviewed with facility staff during the licensing process.
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Plan of Correction
Standard in Non-Compliance
709.91 (b)(6) Intake and Admission
In an effort to re-establish and maintain compliance of standard 709.91 (b)(6), an official review of the Psychosocial evaluation clinical summary has been added to the in-service scheduled for August 20, 2021. During this training, the facilitator will review the elements of psychosocial evaluation and clinical summary, the requirements of completing the clinical summary immediately after gathering clinical and psychosocial data from the Client.
Prior to the date of the official training, Clinical Coordinators will review Psychosocial Evaluation during scheduled supervision sessions to ensure the clinical summary has been completed and contains the required elements.
The Psychosocial Evaluation Clinical Summary is part of the DA Tracker and will be monitored by the DA Committee during scheduled meetings.
A random audit of psychosocial evaluation clinical summaries will be conducted periodically each quarter by the QA department to ensure that Standard 709.91 (b)(6) is being consistently and correctly completed and to ensure that the psychosocial evaluation summaries are being monitored as instructed.
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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, the facility failed to develop an individual's comprehensive treatment and rehabilitation plan with the client in one out of three applicable client records reviewed.Client #2 was admitted on April 12, 2021 and was active at the time of inspection. The comprehensive treatment plan was signed and dated April 12, 2021 by facility staff; however, there was no client signature or written documentation that the plan was developed with the client's input.These findings was reviewed with facility staff during the licensing process.
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Plan of Correction
Standard in Non-Compliance
709.92(a) LICENSURE
Treatment and rehabilitation services:
709.92.
In an effort to address the non-compliance of standard 709.92 (a) Treatment rehabilitation
On July 16, 2021, an in-service was held with the clinical staff. During the in-service training a reviewed of the need to document on the treatment plan and in the progress note during a telehealth visit that involves the updating of a treatment and rehabilitation planning session that the client participated in the development of the rehabilitation and treatment plan and has provided verbal consent in place of a written signature due to the visit type. If however, the client refuses to provide verbal consent at the time of the telehealth visit and wishes to further develop the plan during the next scheduled session. The therapist is to document that the plan was reviewed as scheduled with the client. However, the therapist and client will further review and revise the rehabilitation plan during the next schedule visit. All clinical staff will sign their acknowledgement of their understanding of the need to document verbal consent when conducting telehealth visits during their one-on-one supervision session.
On-Going Monitoring:
Clinical coordinators/supervisors will discuss the importance of this documentation during biweekly supervision along with reviewing applicable charts during the supervision period.
Clinical coordinators/supervisors will review progress notes before approving treatment plans completed via telehealth to confirm verbal consent.
Treatment plans without client signature or progress note explaining why there is no signature will be rejected.
Clinical coordinators will discussed progress with documentation of telehealth treatment planning during Drug and Alcohol committee meetings. Reports of the program performance data will be relayed to chief behavioral officer during biweekly leadership meeting.
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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, the facility failed to a maintain a complete client record on an individual, which includes follow-up information in four of four applicable client records reviewed.Client #4 was admitted on August 2, 2018 and discharged on June 11, 2021. There was no follow-up documentation in the client record as of the date of the inspection. Client #5 was admitted on October 6, 2020 and discharged on February 10, 2021. There was no follow-up documentation in the client record as of the date of the inspection. Client #6 was admitted on September 22, 2020 and discharged on April 23, 2021. There was no follow-up documentation in the client record as of the date of the inspection.Client #7 was admitted on December 26, 2018 and discharged on March 10, 2021. There was no follow-up documentation in the client record as of the date of the inspection.This is a repeat citation from the February 9, 2021 licensing inspection. 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) (11)
In an effort to comply with regulation 709.93 (a)(11), the Admission and Discharge Department manager held a meeting with the Drug and Alcohol committee on July 21, 2021, to review the cases found out of compliance during this inspection and the plan that was put in place to address non-compliance of this standard in March 2021. As a result of this meeting, the Admission and Discharge Department Manager and DA Committee agreed to continue with the plan in place to correct the problem and add one additional check point to enforce compliance.
Client that have failed to complete the program and have received an administrative discharge will not receive follow-up once discharged. Efforts will be made prior to discharge to re-engage the client prior to discharge according to the missed appointment policy.
The Aftercare Plan will not be finalized until all scheduled aftercare activities are completed.
In addition, the follow-up progress note will be completed in the EHR system to documentation all follow-up activity after a program completion discharge.
The Admission and Discharge Department will assist the therapist in staying on track with the established timeline for Client follow-up after program completion.
The Admission and Discharge Department will notify the therapist directly within 72-hours of the needed follow-up, followed by an EHR system reminder within 24-hours of the due date for clients that have successfully completed the program. If the therapist fails to comply and/or is out of the system, the Clinical Supervisor will complete the follow-up, documenting the results in the Client's chart and notifying the therapist in the EHR system of the follow-up activity.
Ongoing monitoring-The Admission and Discharge Manager will perform bi-weekly audits following a baseline audit to ensure that Clients in need of follow-up have been tracked and reported to the Therapist/Clinical Supervisor and have been followed up on according to policy.
Report findings will be submitted to the clinical leadership team monthly.
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