INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 2, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, UPMC Western Behavioral Health of the Alleghenies 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:
|
Plan of Correction
|
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in two out of six applicable charts reviewed.
Client #5 was admitted on August 16, 2024, and was discharged on October 14, 2024. A treatment plan, dated August 21, 2024, indicated one group session and one individual session per week. There was no documentation of an individual session occurring during the five-week period of September 1-October 5, 2024.
Client #6 was admitted on June 10, 2024, and was discharged on August 5, 2024. A treatment plan, dated June 11, 2024, indicated one individual session per week. There was no documentation of an individual session occurring during the four-week period of July 1-July 27, 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
After each completed appointment, counselors will walk with the individual to the administrative assistants to schedule their next appointment to ensure that the next appointment is compliant the frequency identified on the treatment plan. If the next appointment is not in compliance with the treatment plan due to client issue, the administrative assistant will document the reason the individual took a later appointment in the appointment scheduler. If an appointment is incomplete due to an individual not attending their appointment, counselor will contact the individual via telephone in an attempt to reschedule the appointment to ensure that it is compliant with the frequency identified on the treatment plan. Supervisor will review upcoming individual and group appointments during the weekly individual staff supervision. If an individual needs an appointment, the supervisor or counselor will email the administrative assistants with the name of the individual and the date by which they need an appointment to remain compliant with the frequency identified on the treatment plan. The administrative assistant will outreach the individual and email supervisor and counselor with the outcomes of the call. If the appointment the administrative assistant schedules is not in compliance with the treatment plan due to client issue, the administrative assistant will document the reason the individual took a later appointment in the appointment scheduler. The unsuccessful calls will be documented in the EMR by the supervisor or counselor. If there are two unsuccessful outreach attempts, and an appointment cannot be scheduled, an engagement letter will be mailed to the individual. The individual will have two weeks to schedule and attend an appointment before being discharged. |
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.
|
Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in two out of six applicable records reviewed. The facility's policy and procedures manual states that a case consultations will be completed at the time of the comprehensive treatment plan and every sixty days throughout treatment.
Client #5 was admitted on August 16, 2024, and was discharged on October 14, 2024. A comprehensive treatment plan was completed on August 21, 2024, there was no documentation of a case consultation completed on this date.
Client #6 was admitted on June 10, 2024, and was discharged on August 5, 2024. A comprehensive treatment plan was completed on June 11, 2024, there was no documentation of a case consultation completed on this date.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Supervisor and compliance department will change departmental procedure to reflect that case consults are due every 60 days. Supervisor will complete the "documentation tracker spreadsheet" daily. This spreadsheet tracks when case consults were completed and the next due date. Supervisor will provide the staff with a list of case consults that has an upcoming due date weekly. This list lists due dates coming up within the next three weeks. Supervisor will review that case consults are documented in the EMR during the weekly individual staff supervision. |