INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 13, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, GPHA A1-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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to ensure that employee #1, the Chief Executive Officer hired on January 15, 2018, received an annual training plan for the current year based on a review of eight personnel records.The findings were discussed with facility staff during the licensing process
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Plan of Correction
Standard in non-compliance: 704.11(b)(1) LICENSURE
Individual training plan.:
704.11. Staff development program. (b) Individual training plan.
In an effort to correct standard 704.11 (b) (1), and to make certain, compliance is maintained.
Immediately following the Survey, the Chief Behavioral Healthcare officer discussed the findings of the site visit. The CEO was made aware of his responsibility to work with the Chairman of the Board to Develop an annual training plan that was inline with Standard 704.11 (b)(1).
The CEO's Developmental Plan has been completed for this current year, and will be updated in accordance with Standards annually.
Monitoring of compliance:
Credentialing Manager will monitor annually based on the appointed date of renewal.
Quality Assurance Manager will monitor bi-annually to ensure compliance.
Corrective Action Plan: Completed
Monitoring: On-going |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
The facility failed to ensure that all heaters were permanently mounted or installed as a space heater was discovered in room 215, based on the physical plant inspection.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Standard in Non-Compliance
705.26 (2) LICENSURE
Heating and cooling.:
705.26. Heating and cooling. The nonresidential facility: (2) May not permit in the facility heaters that are not permanently mounted or installed.
Observations:
In an effort to meet compliance of standard 705.26 (2) a meeting was held with the Leadership Team immediately following the exit interview to discuss the findings and steps needed to correct the problem. The heater was immediately removed from the facility. During checkout, standard 705.26 (2) and GPHA/Al-Assist's policy on personal heaters were discussed in detail with the facility staff.
In an effort to maintain compliance, checking for heaters in individual offices was added to the security guards daily rounds. In addition, staff have been warned in writing that violation of this standard and GPHA/Al-Assist policy will result in immediate disciplinary action.
Monitory:
Security Officers will check individual offices for heaters during daily walkthroughs at minimum 3x's per day.
QA Manager will review daily walkthrough reports from security officers within 24 hours of completion.
Any infractions will be dealt with immediately and recorded on an incident report and employee write-up. Infractions will be reported to the Chief Behavioral Healthcare officer immediately for final resolve.
Corrective Action: Completed
Monitoring: Ongoing
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to provide treatment plan updates within the regulatory timeframe in five of seven client records reviewed.Client #1 was admitted on April 5, 2017 and was active at the time of inspection. A treatment plan update was completed on February 6, 2018 and the next update was due no later than April 6, 2018. However, the update was not completed until May 24, 2018. Client #2 was admitted on April 19, 2018 and was active at the time of inspection. A comprehensive treatment plan was completed on April 19, 2018 and the next update was due no later than June 19, 2018. However, the update was not completed until July 13, 2018. Client #3 was admitted on November 20, 2017 and was active at the time of inspection. A treatment plan update was completed on May 24, 2018 and the next update was due no later than July 24, 2018. However, the update was not completed until August 25, 2018. Client #6 was admitted on January 23, 2018 and was discharged on September 13, 2018. A treatment plan update was completed on March 6, 2018 and the next update was due no later than May 6, 2018. However, the update was not completed prior to discharge. Client #7 was admitted on January 18, 2018 and was discharged on August 17, 201. A treatment plan update was completed on February 27, 201 and update was due no later than April 27, 2017. However, the update was not completed until May 21, 2018. Additionally, a treatment plan update was completed May 21, 2018 and the next update was due no later than July 21, 2018. However, the update was not completed prior to discharge. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
709.92(b) LICENSURE - TREATMENT AND REHABILITATION SERVICES
CORRECTIVE ACTION:
In an effort to establish and maintain full compliance with regulation 709.92 (b), the findings from the September 13, 2018, were reviewed by the Chief Behavioral Healthcare Officer, Director of Behavioral Health and Coordinator of Behavioral Healthcare Services. As a result of the findings and full review of the cases found in non-compliance the following corrective action plan has been implemented.
The Clinical Supervisors were instructed to develop Performance improvement Plans for those counselors that failed to maintain compliance, with specific goals to address infractions.
In addition:
Another meeting was scheduled with the Clinical Team and Quality Control Clerks and Manager to review Standard 709.92(b) LICENSURE TREATMENT and REHABILITATION: Treatment Plan with a focus on required time-lines for initiating and updated Treatment Plans: How to handle compliant Clients and Non-Compliant Clients when Treatment Plans are due and up for review.
Along with a refresher on:
- Developing Initial Treatment Plans
- Developing Comprehensive Treatment Plans
- Developing Treatment Plan Up-Dates
- Documenting the type and frequency of treatment and rehabilitative services
- Proposed Support Services
-Review of required content
More Importantly, The Quality Control Clerks will conduct daily audits based on the upcoming schedule to ensure Treatment Plan time-lines are in compliance, prior to the members visit. Notification of compliance or pending non-compliance will be emailed to the Counselor and Clinical Supervisor prior to the Member's visit using chart number and appointment date and time only.
Counselor will utilize the daily reports from the QA team to assist them with maintaining compliance.
Monitoring: The QA Control Clerk will monitor following the Member's appointment to ensure that the Treatment Plan was brought into compliance. Notification of findings will be sent to the clinical supervisor immediately and QA Manager.
The Clinical Supervisor will conduct weekly random reviews to ensure that all aspects of the treatment plan is in compliance with standard 709.92.
The QA Manager will report findings to the Leadership team. Additional steps will be implemented immediately if non-compliance continue and/or overall racial for compliance and improvement is not sustained.
TIME FRAME FOR COMPLETION:
In-progress with Ongoing Monitoring
Evaluation of Monitoring Process
Every 60-days By Quality Assurance Manager and Director of Behavioral Health
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