INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on February 11, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated 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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709.24 (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.
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Observations
Based on a review of client records, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in four of seven client records reviewed. The facility policy and procedure manual stated that the comprehensive treatment plan is to be completed within 15 working days from admission. Client # 1 was admitted on November 19, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was due to be completed no later than December 13, 2019; however, the comprehensive treatment plan was not completed until January 2, 2020. Client # 2 was admitted on November 16, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was due to be completed no later than December 2, 2020; however, the comprehensive treatment plan was not completed until December 23, 2020. Client # 7 was admitted on October 24, 2019 and was discharged on May 20, 2020. The comprehensive treatment plan was due to be completed no later than November 14, 2019; however, the comprehensive treatment plan was not completed until March 4, 2020. The facility policy and procedure manual stated that case consultation notes are to be documented every 90 days. Client # 1 was admitted on November 19, 2019 and was still active at the time of the inspection. Case consultation notes were only documented on February 19, 2020. Client # 3 was admitted on December 2, 2019 and was still active at the time of the inspection. Case consultation notes were only documented on June 30, 2020 and January 19, 2021. Client # 7 was admitted on October 24, 2019 and was discharged on May 20, 2020. Case consultation notes were only documented on July 16, 2020. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CORRECTIVE ACTION:
In an effort to maintain compliance with Standard 709.24 (a) (3) and the policy of GPHA/Al-Assist Behavioral Healthcare Center, the Chief Behavioral Healthcare Officer has reviewed and revised the agencies policy on Treatment Planning to coincide with Standard 709.24 (a) (3), removing the need to develop what was referred to by the agency as a Comprehensive Treatment Plan to be developed within 15-working days after the initial/preliminary plan. The revised policy follows the language of Standard 709.24 (a) (3). The revised policy was presented during the in-service on March 19, 2021, with a focus on content, completion timeframe, and correlation with the progress notes. The new policy goes into effect on Friday, March 19, 2021.
In an effort to meet the standards of 709.24 (a) (3) the facility has put the following measures in place. The Clinical Supervisor in conjunction with the Quality Assurance team developed a tracking system for all active cases. The tracker will not display any patient identifying information except for the client record number. The tracker will be reviewed by the Clinical Supervisor, the Counselor IIIs and the Drug & Alcohol Committee on a weekly basis for the first 90 days and monthly thereafter for compliance.
On-going Monitoring: The Site Director will be responsible to provide on-going feedback regarding treatment and rehabilitation management during morning check-in, monthly staff meetings and supervisions.
QA Department will monitor compliance prior and within 24-hours after all scheduled visits. Reports of all findings will be provided to Counselor IIIs, Clinical Coordinators and Clinical Supervisors in an effort to ensure compliance at time of visit.
The DA Committee will review all reports to measure compliance and further develop strategies to ensure compliance at no less than 100% accuracy.
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709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to keep release of information forms within the limits established by 4 Pa. Code 255.5 (b) for releases of information in three of seven client records reviewed. Client # 3 was admitted on December 2, 2019 and was still active at the time of the inspection. The record contained a consent to release information form to the funding source, signed and dated by the client on December 2, 2019, that allowed for the release of the discharge summary/plan, lab results and treatment plan/plan of care, all of which exceed the limits established by 4 Pa. Code 255.5.Client # 4 was admitted on September 8, 2020 and was discharged on December 15, 2020. The record contained a consent to release information form to the funding source, signed and dated by the witness on September 21, 2020, that allowed for the release of lab reports and treatment plan/plan of care, both of which exceed the limits established by 4 Pa. Code 255.5.Client # 7 was admitted on October 24, 2019 and was discharged on May 20, 2020. The record contained a consent to release information form to the funding source, signed and dated by the client on October 24, 2019 that allowed for the release of intake/admission information, plan of care/review, psychiatric evaluation, medications prescribed, psychosocial assessment, discharge summary/plan, all of which exceed the limits established by 4 Pa. Code 255.5.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to meet standard 709.28 (c) (2) Licensure Confidentiality Client currently active in treatment who has a consent that exceed 4 Pa Code 255.5, will be informed that their consent on file has been revoked. Upon next scheduled visit, therapist will update this consent with the Client. The updated consent will be limited to 4 Pa Code 255.5. information to release on the consent shall only include the following: (1) whether the client is or is not in treatment (2) the prognosis of the client, (3) the nature of the project (4) a brief description of the progress of the client and (5) a short statement as to whether the client has relapsed into drug and alcohol abuse and frequency of such relapse.
In addition, all staff members responsible to complete consents to release information will be retrained on the consents/authorizations section within the Electronic Health Record.
Retraining and testing on consents/authorizations policy and workflows based on Drug and Alcohol programs has commenced and shall be completed on March 19, 2021.
The Clinical Supervisor for drug & alcohol services will review all client records to ensure client records meet 709.28 (c)(2) Confidentiality.
Monitoring: The Clinical Coordinator and Site Director will be responsible to monitor client records to ensure staff are following the proper workflow that would prohibit the release of information that would exceed the limits established by 4 Pa Code 255.5.
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709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review client records, the facility failed to document the dated signature of the client on release of information forms in three of seven client records reviewed. Client # 1 was admitted on November 19, 2019 and was still active at the time of the inspection. The release of information form to another treatment provider was signed and dated by the witness on February 11, 2020 but the form was not signed by the client. Client # 4 was admitted on September 8, 2020 and was discharged on December 15, 2020. The release of information form to the DUI coordinator was signed and dated by the witness on January 25, 2021 but the form was not signed by the client. The release of information forms to the emergency contact, the laboratory, and the funding source were signed and dated by the witness on September 21, 2020 but the forms were not signed by the client. Client # 6 was admitted on June 26, 2020 and was discharged on December 28, 2020. The release of information form to the parole officer was signed and dated by the witness on August 3, 2020 but the form was not signed by the client. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
CORRECTIVE ACTION:
In an effort to address the deficiency associated with standard 709.28 (c)(4) Confidentiality: Site Director held a meeting on March 5, 2021, with the site. A copy of Regulation 709.28 (c)(4) was distributed and read. Further explanation was provided detailing the importance of obtaining a client signature on consent documentation based on standard 709.28 (c)(4). Staff were asked to sign the document, attesting that they have reviewed and understand the regulation.
Any consent to release information obtained during the pandemic that indicated the Client provided verbal consent during a telehealth visit will be revoked immediately.
Signatures for new consents will be obtained electronically through the technology of DocuSign for Clients unwilling to come on-site due to the pandemic and related/compromised medical conditions. Clients who do not have the technology or skills to use DocuSign will not be required to sign any consents involving release/disclosure until the Clients is comfortable coming on-site for services. Clients who agree to receiving their consents via U.S. Mail will be required to sign, date and place the consents in the return stamped envelope during the virtual telehealth visit, so that the consents can be witnessed by the therapist. All required signatures and dates will be captured on-site using the standard signature pad for Clients during face-to-face for those who are willing to receive and provide services on site using PPE and practicing social distancing. Effective March 5, 2021, no consent will be captured unless all signature capturing technology is fully operating that allows all parties the ability to sign and date the consent. Consents received back via U.S. Mail will be signed by the witnessing therapist and scanned into the Client's electronic health record.
The Discharge and Admissions Department will review new admits within 24-hours to ensure compliance of standard 709.28 (c) (4). Clinical Coordinator/Supervisor will conduct periodic audits reviewing consents in preparation for biweekly supervision meetings.
Monitoring will be Ongoing by Site Director and Quality Assurance (QA) Department to measure progress and compliance. Audit findings will be reported to Leadership Team and Chief Behavioral Health Officer during bi-weekly Leadership meetings.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client in each release of information form in seven out of seven client records reviewed. Client # 1 was admitted on November 19, 2019 and was still active at the time of the inspection. The release of information form was signed by were signed by the client and witness on November 19, 2020 and by the witness on February 11, 2020 but they did not document that a copy of the consent was offered to the client. Client # 2 was admitted on November 6, 2020 and was still active at the time of the inspection. The release of information forms were signed by the client and witness on December 23, 2020 and November 6, 2020 but they did not document that a copy of the consent was offered to the client. Client # 3 was admitted on December 2, 2019 and was still active at the time of the inspection. The release of information forms were signed by the client and witness on December 2, 2019 but they did not document that a copy of the consent was offered to the client. Client # 4 was admitted on September 8, 2020 and was discharged on December 15, 2020. The release of information forms were signed by the client and witness on September 8, 2020 and by the witness on January 25, 2021 and September 21, 2020 but they did not document that a copy of the consent was offered to the client. Client # 5 was admitted on September 25, 2020 and was discharged on January 15, 2021. The release of information forms were signed by the client and witness on September 25, 2020 but they did not document that a copy of the consent was offered to the client. Client # 6 was admitted on June 26, 2020 and was discharged on December 28, 2020. The release of information forms were signed by the client and witness on June 26, 2020 and by the witness on August 3, 2020 but they did not document that a copy of the consent was offered to the client. Client # 7 was admitted on October 24, 2019 and was discharged on May 20, 2020. The release of information forms were signed by the client and witness on November 8, 2019 and October 24, 2019 but they did not document that a copy of the consent was offered to the client. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CORRECTIVE ACTION:
To comply with regulation 709.28 (d) Confidentiality, documentation will be visible in the client record to show that the Provider offered a copy of the client consent to the client in each release of information, and that the client accepted or refused a copy of the consent. A copy of the consents will be maintained in the client record.
The findings concluded that the section of the Electronic Health Record where it should be indicated that the client accepted or refused a copy of the consent was missing, and the EHR system did not show a copy offered when printed or displayed on screen. This section of the form did show on screen when a new form was added. The issue has been reported to the Chief Behavioral Health Officer. The EHR glitch will be corrected no later than April 15, 2021.
Upon completion of a release of information, Registration Assistant, Urgent Care Specialist, or Counselor III will offer the client a copy and check the box to indicate a copy was offered or refused. Effective 3/5/21, Registration Assistant, Urgent Care Specialist, or Counselor III will document in a note that they have offered the client a copy of the Consent/Release of Authorization and indicate that the client accepted or refused a copy.
Monitoring: The Site Director along with the Clinical Coordinator/Supervisor will provide ongoing monitoring of client records to ensure compliance with regulation 709.28 (d). Audit findings will be reported to Leadership Team, Quality Assurance Department, and Chief Behavioral Health Officer during bi-weekly Leadership meetings.
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