INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 25, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, John F. Kennedy 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:
|
Plan of Correction
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure each counselor completed at least 25 hours of training annually in one of one applicable personnel record reviewed.
Employee #3 was hired as a counselor on March 14, 2023. The personnel record documented 10 hours of annual training for the July 1, 2023 through June 30, 2024 training year reviewed.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
0083: 704.11(f)(2) Licensure Trng Hours Req-Coun:
All counselors will complete at least 25 clock hours of training annually in areas such as (i) Client recordkeeping, (ii) Confidentiality, (iii) Pharmacology, (iv) Treatment planning, (v) Counseling techniques, (vi) Drug and Alcohol Assessment, (vii) Codependency, (viii) Adult Children of Alcoholics (ACOA) issues, (ix) Disease of addiction, (x) Aftercare planning, (xi) Principles of Narcotics Anonymous, (xii) Ethics, (xiii) Substance abuse trends, (xiv) Interaction of addiction and mental illness, (xv) Cultural awareness, (xvi) Sexual harassment, (xvii) developmental psychology, and (xvii) Relapse prevention. The Clinical Supervisor will create a training plan with each counselor on an annual basis to complete the 25 required clock hours of training in the above domains. The Clinical Supervisor will then review the counselors training hours in weekly supervision to ensure that the counselor obtains the 25 required clock hours of training annually.
The Clinical Supervisor will submit each training certificate to Quality Assurance for monitoring of this practice.
Completion Date: 1/1/2025
|
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.
|
Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in four of seven client records reviewed.
The facility policy and procedure manual stated that individual treatment and rehabilitation plans are to be completed within 30 days of admission. Additionally, the facility policy and procedure manual also stated that case consultation notes are to be completed every 90 days.
Client # 1 was admitted on March 29, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan was due to be completed no later than April 29, 2024; however, the plan was completed on May 31, 2024. Additionally, a case consultation note was completed on April 10, 2024 and the next one was due no later than July 10, 2024; however, there was not a second case consultation note completed as of the date of the inspection.
Client # 2 was admitted on May 30, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan was due to be completed no later than June 30, 2024; however, the plan was completed on August 22, 2024.
Client # 3 was admitted on December 1, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was due to be completed by January 1, 2024; however, the plan was completed on March 13, 2024. Additionally, a case consultation note was due to be completed no later than March 1, 2024; however, the note was completed on March 11, 2024. The next case consultation note was due no later than June 11, 2024; however, there was not a case consultation note completed as of the date of the inspection.
Client # 7 was admitted on March 22, 2024 and was discharged on June 14, 2024. The individual treatment and rehabilitation plan was due to be completed by April 22, 2024; however, the plan was completed on May 13, 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
0157: 709.24(a)(3) Licensure Treatment/rehabilitation management:
As per JFK's facility policy and procedure manual, all clients who are active in treatment will have their individual treatment and rehabilitation plan completed within 30 days of admission. Additionally, all clients who are active in treatment will have their case consultation notes completed every 90 days. The Clinical Supervisor will perform a weekly review of counselor case management logs to identify all upcoming treatment plans (including new admissions) and case consultation notes. Counselors will be instructed to complete these treatment plans and case consultation notes prior to expiration.
To ensure that these timelines are adhered to, Quality Assurance will monitor the completion of these documents and compliance of this practice during chart reviews.
Completion Date: 11/20/2024
|
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
|
Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information contained in the client record in one of seven client records reviewed.
Client # 3 was admitted on December 1, 2023 and was active at the time of inspection. The funding source consent to release information form was signed by the client on February 29, 2024. However, there was evidence of disclosures to the funding source prior to February 29, 2024 and there was no consent to release information form signed by the client in the record prior to February 29, 2024.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
0276 : 709.28 (c) Licensure Confidentiality:
Every active client in treatment will meet in-person with their counselor to complete annual releases of information. Every consent form, including but not limited to: funding source; transportation agency; primary care physician; and emergency contact will contain the dated signature of the client. The Clinical Supervisor, prior to approving clinical service notes to be submitted for billing, will ensure that there is an active voluntary release of information for the funding source with a physical signature of both the client and the witness. Notes that do not comply with this procedure will be held back for submission until the person has signed the required release of information form.
Quality Assurance will monitor the implementation of this procedure during compliance review of charts.
Completion date: 11/20/2024
|
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:
|
Observations
Based on a review of client records, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client in two of six applicable client records reviewed.
Client #5 was admitted on March 25, 2024 and was discharged on June 14, 2024. There was no documentation in the record indicating there was an individual treatment and rehabilitation plan completed with the client at the time of the inspection.
Client #6 was admitted on June 26, 2024 and was discharged on September 11, 2024. There was no documentation in the record indicating there was an individual treatment and rehabilitation plan completed with the client at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
1875 : 709.92(a) Licensure Treatment and rehabilitation services:
All clients who are active in treatment will have their treatment plans reviewed and updated at least every 30 days for new admissions and 60 days thereafter. The Clinical Supervisor will perform a weekly review of counselor case management logs and identify all upcoming treatment plans in supervision. Counselors will be instructed to complete these treatment plan updates prior to expiration. This will also be a topic of each staff meeting to reinforce the importance of maintaining current treatment plan documentation for all active clients.
Quality Assurance will monitor the completion and compliance of this practice during chart reviews.
Completion Date: 11/20/2024
|
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 a maintain a complete client record on an individual, which is to include case consultation notes, in one of three applicable client records reviewed.
Client #2 was admitted on May 30, 2024 and was active at the time of inspection. There was no documentation of a case consultation note in the record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
1905: 709.93(a)(8) Licensure Client Records
The Clinical Supervisor will provide Counselor training on documenting client case consultation notes in the Electronic Health Record. During weekly supervision, the Clinical Supervisor will review upcoming case consultations with the Counselor and will ensure that documentation is completed by the Counselor at least every 90 days in the Electronic Health Record.
Quality Assurance will monitor the completion and compliance of this practice during chart reviews.
Completion Date: 11/20/2024
|