Observations
Based on a review of client records, the facility failed to document the frequency of treatment and rehabilitation services on the client's individual treatment and rehabilitation plan in four of seven client records reviewed.
Client #1 was admitted on October 19, 2022 and was active at the time of inspection. The individual treatment and rehabilitation plan did not include what the frequency of services provided to the client were to be.
Client #2 was admitted on November 17, 2022 and was active at the time of inspection. The individual treatment and rehabilitation plan did not include what the frequency of services provided to the client were to be.
Client #3 was admitted on August 22, 2022 and was active at the time of inspection. The individual treatment and rehabilitation plan did not include what the frequency of services provided to the client were to be.
Client #4 was admitted on January 11, 2023 and was discharged on July 27, 2023. The individual treatment and rehabilitation plan for the client did not include written documentation of the frequency of services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Citation #: 0965
Date to be Completed By: 8/30/23.
Responsible Party: Facility and Program Director ("Director") for Behavioral Health
Action:
Following the observation, the Program Director reviewed the DDAP regulation 711.92 with the staff present following the survey findings.
The Director reinforced that the treatment and rehabilitation services must relate to an individual treatment and rehabilitation plan developed in collaboration with the client. The director reinforced that the plan shall include, but not be limited to, written documentation of the Type and frequency of treatment and rehabilitation services.
The Program Director reviewed Policy 22.03 Individualized Master Treatment Plan, 22.04 Treatment Planning ? Problem Specific, and 22.05 Treatment Plan Updates and confirmed it included the type and frequency of treatment and rehabilitation services specified in the policy. No policy changes were required.
The survey results and a documentation review revealed an opportunity to improve treatment plans by adding the type and frequency into the notes section of each intervention.
The Program Director ensured Cognitive Behavioral Therapy (CBT) and Ecosystemic Structural Family Therapy (ESFT) treatment plans built in the Electronic Medical Record (EMR) specifically for clinical interventions occurring in the program are available for clinician use.
Re-education to staff was provided on the policy 22.08 Individualized Master Treatment Plan, as well as the use of the specific programmatic treatment plans for the use of CBT and ESFT. The treatment plans are detailed to our programmatic theoretical orientations that add specificity to clinician intervention to improve treatment plans.
The Program Director implemented a Tip Sheet to use treatment plans and direction on where to input frequency and timeframes within the intervention.
The education plan was implemented with education to counselors completed by 8/14/23. Clinicians signed on the training sign-in sheet acknowledging their understanding of the process and expectation of adding timeframes and frequency of each intervention. The Program Director confirmed that all counselors received documented training. Any new hires will receive this education in orientation.
The Program Director will use trained staff to audit approximately 30 charts/month, which will be audited to verify sustained treatment plan compliance for the next six months. If there are not 30 records applicable records, then 100% of the charts will be reviewed.
Program Director or designee will report results to the Penn Presbyterian Medical Center (PPMC) Clinical Effectiveness and Quality Improvement (CEQI) Committee as part of PPMC's ongoing quality assurance and performance improvement activities. The Committee will evaluate the results, provide constant staff feedback, and implement any further process changes and audits as needed.
Active Client Review:
Client #1 and Client # 3 noted in the findings remain active patients. As a result, their treatment plans were updated with the frequency and timeframe expectations outlined in DDAP regulation 711.92.
Former Client Review:
Client #2, active at the time of inspection, was discharged before implementing this improvement plan; the treatment plan was not updated as it was marked as completed before the patient's discharge. Compliance will be expected if the patient resumes care as outlined in the regulation, policy, and education provided.
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