INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 22-23, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, 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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709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
Based on a review of administrative documentation, a letter issued to The Department from the facility director, and a conversation with the facility director; the facility failed to identify the CEO, who reports to the governing body and carries out the project's administrative duties, as the project director.The findings include:On August 22, 2012 a review of administrative documentation revealed that the employee identified as the project director, employee # 1, does not report to the governing body/Board of Directors, but reports to the CEO. The project's CEO is ultimately responsible to the governing body. A letter dated October 28, 2011 from the facility to the Department identified the CEO as qualifying for the position of project director, however the facility did not identify the CEO as the project director in any of the documentation presented during the licensing inspection.The facility director, employee # 2 was interviewed regarding the findings, at which time she confirmed that the employee identified as the project director is not officially responsible to the governing body.
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Plan of Correction
Plan of Correction:
Standard in Noncompliance
709.22(d)(1) LINCENSURE Governing Body
In effort to comply with regulation 709.22(d)(1) the written findings from August 22, 2012 were discussed once again with the Director of Behavioral Health, Chief Executive Officer, and the Governing Body. It was unanimously decided that based on 709.22(d)(1) regulations and reporting structure of the organization. The Chief Executive Officer is the only person responsible to the governing body and reports directly to the Board of Directors; therefore moving forward, the CEO will be the project director for our Drug and Alcohol Program.
Correction time: Completed
Monitoring is on-going
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician for 24-hour emergency medical and psychiatric coverage.The findings include:The letters of agreement were reviewed on August 23, 2012. No letter of agreement regarding 24- hour emergency medical and psychiatric coverage was documented. The facility had a letter in place signed by employee #1 which stated she would ensure that emergency medical and psychiatric services would be provided if needed by one of the project's clients; however there was no agreement in place with a specific hospital or physician.
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Plan of Correction
Plan of Correction:
Standard
709.24(d) TREATMENT/REHABILITATION MANAGEMENT
In an effort to maintain compliance with regulation 709.24(d)
The Director of Behavioral Healthcare will make obtain that formal Letters of Agreement with Licensed hospitals and Physicians for 24-hour emergency medical and psychiatric coverage are obtained for Al-Assist Beahvioral Healthcare Center and GPHA Inc. Al-Assist Behavioral Healthcare Center.
The Director of Behavioral Healthcare will develop a written letter of agreement for 24-hour emergency medical and psychiatric coverage.
The Clinical Coordinator wiill forward the letter of agreement to Medical Doctors and Psychiatrists for their signature of acceptance.
Upon retrievemnet of the signed letter of agreements for 24-hour emergency medical and psychiatric coverage. The Clinical Coordinator will fax the completed letters of agreement to DDAP prior to November 30, 2012.
In addition, the Quality Assurance Coordinator will contact surrounding Hospitals to obtain formal Letters of Agreement indicating 24-hour emergency medical and/or psychiatric coverage.
Upon retrievement of the signed letter of agreements for 24-hour emergency medical and psychiatric coverage. The Quality Assurance Coordinator will collaborate with the Clinical Coordinator to fax the completed letters of agreement to DDAP prior to December 15, 2012.
Annually, In November, request for 24-hour emergency psychiatric and medical coverage will be forwarded to licensed physicians, psychiatrist and hospitals.
Completion Date: 12/15/2012
Monitored:
24-hour emergency care coverage will be monitored by the Director of Behavioral Health and Quality Assurance Department periodically to ensure complaince.
Correction time-frame for formal written letters of agreements with 2 or more Medical Providers: November 30, 2012 and Hospital December 15, 2012.
Monitoring on-going
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709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
Based on a review of the policy and procedure manual and client intake documentation, the project failed to document a client rights policy indicating the client has the right to appeal a decision limiting access to his records to the project director.The findings include:The policy and procedure manual and client intake documentation was reviewed on August 22, 2012. There was no documentation of the clients' right to appeal a decision limiting access to his records to the project director. The facility director was interviewed on August 22, 2012 and confirmed this policy was not in the project's policy and procedure manual.
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Plan of Correction
Plan of Correction:
Standard in Noncompliance
709.30(4)LINCENSURE Client Rights
In effort to comply with regulation 709.30(4)the written findings from August 22, 2012 were discussed with the Executive staff. As a result of the discussion and in review of the existing policy of Client's Rights. A revision was made to include the following language: The Client has the right to appeal a decision limiting access to his/her records to the project director.
Notice of the revised Client's Rights policy has been posted at the facility highlighing the revision.
Revised policy has been placed in the Program's operating Manual.
Revised policy is included in the intake package for new admits and in the client's annual update packages.
Person Responsible:
Director of Behavior Health
Time Frame for Completion: Completed
Monitoring: Quality Assurance Department randomly.
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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 upon a review of the facility's policies and procedures and client records, the facility failed to document the clients' medical history in accordance with facility policy in two of five client records.The findings include:The policies and procedures manual was reviewed on August 22, 2012. The policy referring to the biopsychosocial assessment included the following language, which specified the timeframe for the completion of medical histories: "Part 1 of the comprehensive biopsychosocial assessment is to be completed within 15 work days."Five client records requiring documentation of medical histories were reviewed on August 23, 2012. Two of five client records, specifically client records # 1 and 3, did not include documentation of medical histories. Client #1 was admitted to treatment on March 9, 2012 and was discharged on June 2, 2012. The medical history was due by March 30, 2012. As of August 23, 2012, there was no documentation of a medical history. Client #3 was admitted to treatment on October 27, 2011 and was discharged on March 9, 2012. The medical history was due by November 18, 2011. As of August 23, 2012, there was no documentation of a medical history. The findings were reviewed with two quality assurance staff, the clinical director, and the facility director prior to the exit interview.
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Plan of Correction
Re: L 1861:
Corrective Action:
The Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will provide training all Drug/Alcohol Counselors on the Comprehensive Bio-psychosocial Evaluation, which will include the following training areas:
-time frame for completing the CBE
-instructions for fully completing the medical section
-instructions for fully completing the drug/alcohol history section
-instructions for fully completing the personal history section
-required components to be assessed when completing CBE's.
-strategies for ensuring that all CBE's are evaluative and reflect the counselor's conclusions/impressions.
Additionally, the Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will conduct weekly random record reviews to ensure that all CBE's are done in accordance with GPHA, Inc.'s policies and procedures and DDAP standards.
Persons Responsible:
Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator
Time Frame for Completion:completed
September 21, 2012 / Ongoing
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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 upon a review of the facility's policies and procedures and client records, the facility failed to document the clients' drug and/or alcohol history in accordance with facility policy in two of five client records.The findings include:The policies and procedures manual was reviewed on August 22, 2012. The policy referring to the biopsychosocial assessment included the following language, which specified the timeframe for the completion of drug and/or alcohol histories: "Part 1 of the comprehensive biopsychosocial assessment is to be completed within 15 work days."Five client records requiring documentation of drug and/or alcohol histories were reviewed on August 23, 2012. Two of five client records, specifically client records # 1 and 3, did not include documentation of drug and/or alcohol histories. Client #1 was admitted to treatment on March 9, 2012 and was discharged on June 2, 2012. The drug and/or alcohol history was due by March 30, 2012. As of August 23, 2012, there was no documentation of a drug and/or alcohol history. Client #3 was admitted to treatment on October 27, 2011 and was discharged on March 9, 2012. The drug and/or alcohol history was due by November 18, 2011. As of August 23, 2012, there was no documentation of a drug and/or alcohol history. The findings were reviewed with two quality assurance staff, the clinical director, and the facility director prior to the exit interview.
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Plan of Correction
Re: L1863
Corrective Action:
The Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will provide training all Drug/Alcohol Counselors on the Comprehensive Bio-psychosocial Evaluation, which will include the following training areas:
-time frame for completing the CBE
-instructions for fully completing the medical section
-instructions for fully completing the drug/alcohol history section
-instructions for fully completing the personal history section
Additionally, the Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will conduct weekly random record reviews to ensure that all CBE's are done in accordance with GPHA, Inc.'s policies and procedures and DDAP standards.
Persons Responsible:
Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator
Time Frame for Completion:completed
September 21, 2012 / Ongoing
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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 upon a review of the facility's policies and procedures and client records, the facility failed to document the clients' personal history in accordance with facility policy in two of five client records.The findings include:The policies and procedures manual was reviewed on August 22, 2012. The policy referring to the biopsychosocial assessment included the following language, which specified the timeframe for the completion of personal histories: "Part 1 of the comprehensive biopsychosocial assessment is to be completed within 15 work days."Five client records requiring documentation of personal histories were reviewed on August 23, 2012. Two of five client records, specifically client records # 1 and 3, did not include documentation of personal histories. Client #1 was admitted to treatment on March 9, 2012 and was discharged on June 2, 2012. The personal history was due by March 30, 2012. As of August 23, 2012, there was no documentation of a personal history. Client #3 was admitted to treatment on October 27, 2011 and was discharged on March 9, 2012. The personal history was due by November 18, 2011. As of August 23, 2012, there was no documentation of a personal history. The findings were reviewed with two quality assurance staff, the clinical director, and the facility director prior to the exit interview.
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Plan of Correction
Re: L 1865
Corrective Action:
The Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will provide training all Drug/Alcohol Counselors on the Comprehensive Bio-psychosocial Evaluation, which will include the following training areas:
-time frame for completing the CBE
-instructions for fully completing the medical section
-instructions for fully completing the drug/alcohol history section
-instructions for fully completing the personal history section
Additionally, the Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will conduct weekly random record reviews to ensure that all CBE's are done in accordance with GPHA, Inc.'s policies and procedures and DDAP standards.
Persons Responsible:
Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator
Time Frame for Completion:Completed
September 21, 2012 / Ongoing
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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 a psychosocial evaluation that included an assessment of the client's assets and strengths, support systems, coping mechanisms, negative factors that may affect treatment, attitude towards treatment, the counselor's conclusions and/or impressions, or failed to document a biopsychosocial evaluation at all in four of six client records. The findings include:The policies and procedures manual was reviewed on August 22, 2012. The policy referring to Part 2 of the comprehensive biopsychosocial assessment included the following language, which specified the timeframe for the completion of psychosocial evaluations: "Part 2 of the comprehensive biopsychosocial assessment is to be completed within 30 work days."Six client records requiring documentation of psychosocial evaluations were reviewed on August 23, 2012. Four of six client records, specifically client records # 2, 4, 5, and 6, did not include documentation of a psychosocial evaluation that was inclusive of an assessment of the client's assets and strengths, support systems, coping mechanisms, negative factors that may affect treatment, attitude towards treatment, the counselor's conclusions and/or impressions. Two of six client records did not include documentation of a psychosocial evaluation, specifically client records # 1 and 3.Client #1 was admitted to treatment on March 9, 2012 and was discharged on June 2, 2012. The psychosocial evaluation was due by April 20, 2012. As of August 23, 2012, there was no documentation of a psychosocial evaluation for client #1. Client #2 was admitted to treatment on March 21, 2012 and discharged on August 3, 2012. The psychosocial evaluation was completed on April 3, 2012 and did not include a clinical assessment of the client's assets and strengths, support systems, coping mechanisms, negative factors that can affect treatment, attitude towards treatment, and the counselor ' s conclusions and impressions.Client #3 was admitted to treatment on October 27, 2011 and was discharged on March 9, 2012. The psychosocial evaluation was due by December 9, 2011. As of August 23, 2012, there was no documentation of a psychosocial evaluation for client #3. Client #4 was admitted to treatment on July 26, 2012. The psychosocial evaluation was completed on August 3, 2012 and did not include a clinical assessment of the client's assets and strengths, support systems, coping mechanisms, negative factors that can affect treatment, attitude towards treatment, and the counselor ' s conclusions and impressions.Client #5 was admitted to treatment on July 31, 2012. The psychosocial evaluation was completed on July 31, 2012 and did not include a clinical assessment of the client's assets and strengths, support systems, coping mechanisms, negative factors that can affect treatment, attitude towards treatment, and the counselor's conclusions and impressions.Client #6 was admitted to treatment on June 18, 2012. The psychosocial evaluation was completed on June 18, 2012 and did not include a clinical assessment of the client's assets and strengths, coping mechanisms, negative factors that can affect treatment, attitude towards treatment, and the counselor's conclusions and impressions.The findings were reviewed with two quality assurance staff, the clinical director, and the facility director prior to the exit interview.
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Plan of Correction
Re: L 1871
Corrective Action:
The Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will provide training to all Drug/Alcohol Counselors on the Comprehensive Bio-psychosocial Evaluation, which will include the following areas:
-time frame for completing the CBE
-instructions for fully completing the medical section
-instructions for fully completing the drug/alcohol history section
-instructions for fully completing the personal history section
-required components to be assessed when completing CBE's.
-strategies for ensuring that CBE's are evaluative and reflect the Counselor's onclusions/impressions.
Additionally, the Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will conduct weekly random record reviews to ensure that all CBE's are done in accordance with GPHA, Inc.'s policies and procedures and DDAP standards.
Charts Currently out of Compliance:
Counselor (s) Client Record's deemed out of compliance will be required to revisit the psychosocial evaluation with their Client in an effort to gather comprehensive information from the client to formulate a comprehensive assessment of all areas outlined under 709.91(b)(6) Licensure Intake and Admisiion along with the counselor's conclusions, impressions and prognosis.
Persons Responsible:
Counselor
Clinical Coordinator and Quality Assurance Coordinator
Time Frame for Completion:Training Completed
Correction of Existing Charts to be completed by: November 23, 2012
Monitoriny: Ongoing: Clinical Coordinator and Quality Assurance
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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 upon a review of the facility's policies and procedures and client records, the facility failed to document the clients' comprehensive treatment plans in accordance with facility policy in two of five client records.The findings include:The policies and procedures manual was reviewed on August 22, 2012. The policy referring to the comprehensive treatment plan included the following language:"Comprehensive treatment plans are to be documented within 15 work days."Five client records requiring documentation of a comprehensive treatment plan were reviewed on August 23, 2012. Two of five client records, specifically client records # 3 and 4, did not include documentation of a comprehensive treatment plan.Client #3 was admitted to treatment on October 27, 2011 and was discharged on March 9, 2012. The comprehensive treatment plan was due by November 18, 2011. As of August 23, 2012, there was no documentation of a comprehensive treatment plan for client #3.Client #4 was admitted to treatment on July 26, 2012. The comprehensive treatment plan was due by August 16, 2012. As of August 23, 2012, there was no documentation of a comprehensive treatment plan for client #4.The findings were reviewed with two quality assurance staff, the clinical director, and the facility director prior to the exit interview.
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Plan of Correction
L 1875
Corrective Action:
The Drug/Alcohol Clinical Coordinator and the Quality Assurance Coordinator will provide training to all Drug/Alcohol Counselors on Treatment Plans, which will include the following: time Frame for completion of treatment plans and how to develop relevant, achievable and measurable treatment plans goals and action steps.
Additionally, the Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will conduct weekly (random) reviews of clinical records to ensure that all clients have current treatment plans.
Charts Deemed our of Compliance at time of audit:
Counselor (s) Client Record's deemed out of compliance at time of audit completed a comprehensive treatment plan during the Client first individual sessions following the deficiency notice. Currently, all active charts contain a comprehensive treatment plan.
Persons Responsible:
Counselor
Clinical Coordinator and Quality Assurance Coordinator
Time Frame for Completion:Training Completed
Correction on Previously Out of Compliance Charts: Completed
Monitoriny: Ongoing: Clinical Coordinator and Quality Assurance
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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 upon a review of the facility's policies and procedures and client records, the facility failed to document case consultations in accordance with facility policy in one of two client records.The findings include:The policies and procedures manual was reviewed on August 22, 2012. The policy referring to case consultations included the following language: "Case consultations are to be completed every 90 days."Two client records requiring documentation of case consultations were reviewed on August 23, 2012. One of two client records, specifically client record # 3, did not include documentation of a case consultation.Client #3 was admitted to treatment on October 27, 2011 and was discharged on March 9, 2012. The case consultation was due by January 27, 2012. As of August 23, 2012, there was no documentation of a case consultation for client #3. The findings were reviewed with two quality assurance staff, the clinical director, and the facility director prior to the exit interview.
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Plan of Correction
L 1905:
Corrective Action:
The Drug/Alcohol Clinical Coordinator will provide training to all Drug/Alcohol Counselors on conducting and documenting case consultations, which will include time frame for completing case consultations, and how to accurately complete the case consultation form. Additionally, the Drug/Alcohol Clinical Coordinator and Quality Assurance Coordinator will conduct random reviews of clinical records to ensure that case consultations have been conducted and completed, as Al-Assist policy.
Persons Responsible:
Drug/Alcohol Clinical Coordinator
Time Frame for Completion:
October 11, 2012 / Ongoing
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