INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, GPHA 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 and a plan of correction is due on October 15, 2009.
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Plan of Correction
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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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of five client records on September 11, 2009, the facility failed to document informed and voluntary consents that included specific information to be disclosed in three of five client records where required.Findings:A review of five client records was conducted on September 11, 2009. Of those records, three, #1,#2 and #5, contained informed and voluntary consents signed by the client, but did not indicate what specific information was to be disclosed. Additionally, record #2 indicated that information was released to an outside entity without written consent from the client.
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Plan of Correction
Plan of Correction:
Standard in Noncompliance
709.28 (c)Confidentiality
In an effort to comply with regulation 709.28, the written findings from the September 11, 2009 were reviewed in detail with the Clinical Coordinators and Counselor III during the clinical staff meeting to again review Standard 709.28 and the agency's Confidentiality policy and procedures supportive of Standard 709.28(c)/4 Pa code Subsection 255.5(b), and to reiterate the importance of accurately documenting on the informed and voluntary consent form the specific information to be released/disclosed with the clear understanding that the released/disclosed information must not be released without a signed written consent and must not exceed the limitation set forth in 4 Pa Code Subsection 255.5(b): 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 and frequency of such relapse. In addition, medical record clerks were instructed to review consent forms routinely to ensure that no infractions of regulation 709.28 have been made. In addition, medical record clerks and clinical staff were instructed to do away with all old blank consent to release forms that did not indicate in writing what information was to be released in accordance with regulation 709.28, and to only utilize the consent to release forms designated for consumers in the drug and alcohol outpatient program that reference specific guidelines outlined in regulation 709.28.
Correction: 10/09/09 Monitoring Ongoing |
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:
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Observations
Based on a review of five client records on September 11, 2009, the facility failed to complete client comprehensive treatment plans within the timeframe specified in facility policies. Findings:On September 11, 2009, five client records were reviewed. Facility policy requires that treatment plans must be completed within 15 days of client admission. Two of five records did not show completion of the comprehensive treatment plans within the required timeframe. The client 's admission date in record #2 was 8/5/08 and the comprehensive treatment plan was due to be completed by 8/26/09, however, it was not completed until 3/31/09. Record # 3 revealed the admission date as 9/22/08. The comprehensive treatment plan was due to be completed by 10/13/08; however, it was not completed until 11/13/08.
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Plan of Correction
A meeting was held with the Executive Staff and Clinical Coordinators to review findings from September 11, 2009 audit. In an effort to comply with regulation 709.92 and in an effort to realistically meet the facility's policy regarding completion time of the Comprehensive Treatment Plan from the date of admission/Preliminary Treatment Plan, The Comprehensive Treatment Plan policy was revised to read as follows: Comprehensive Treatment Plan must be completed within 15 working days from client's admission date. With the following exception, if client fails to attend his/her scheduled individual sessions with his/her assigned primary counselor within 15 working days from date of admission but, prior to day 31 from date of admission, the Comprehensive Treatment Plan must be completed at first face to face encounter with his/her assigned primary counselor. The revised policy has been distributed to all clinical staff. In addition, the Treatment Plan Compliance Auditing Team will randomly audit Treatment Plans the 2nd Friday of each month based on regulation 709.92 and the agencies policy on treatment plan documentation. Findings from the audit will be analyzed and given to the Clinical Coordinators to review with counselors during weekly supervision sessions. Counselors identified as inadequate in treatment planning will receive additional support from the Clinical Coordinators. Counselors who fail to demonstrate improvement in the area of treatment planning despite additional support will be terminated no more than 60 days from the initial date deemed inadequate. Newly hired staff will not successfully pass orientation without demonstrating knowledge of the timelines for completing treatment plans and a clear understanding of how to clinically document the content of the treatment plan.
Correction Time: Complete
Monitoring: On-going
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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
Based on a review of five client records on September 11, 2009, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in two of five records. Findings:On September 11, 2009, five client records were reviewed. In record #2, the initial comprehensive treatment plan was dated 3/31/09. A review of the plan was due by 5/31/09 but had not been completed until 7/5/09. The initial comprehensive treatment plan of record #3 was dated 11/13/08 and was due to be reviewed by 1/13/09. However, the update did not occur until 3/23/09.
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Plan of Correction
Plan of Correction:
A meeting was held with the Executive Staff and Clinical Coordinators to review findings from September 11, 2009 audit. In an effort to comply with regulation 709.92 and in an effort to realistically meet the facility's policy regarding completion time of the Treatment Plan Updates. The Treatment Plan Update policy was revised to read as follows: Treatment Plan Updates must be completed at within 60 days from client's last update. If the Client is scheduled for an individual session with his/her primary counselor within 5 working days prior to the Treatment Plan Update (due date) the treatment plan update should be completed with the Client during that scheduled session to ensure Client's participation in the treatment planning process. If Client fails to attend scheduled appointments within 5 working days of the treatment plan update (due date)or on the date of the due date. The Counselor must complete the Treatment Plan Update as scheduled and review with Client at his/her first face to face encounter and obtain Client's signature; documenting on the Treatment Plan Update that the signature date represents the first face to face encounter with the Client past the scheduled Treatment Plan Update (due date). The revised policy will be distributed to all clinical staff upon approval. In addition, Clinical staff has been instructed to keep a log sheet of his/her caseload indicating dates for Treatment Plan Updates, Case Consultations, Level Changes, and etc. Clinical Staff were instructed to review this log daily to avoid documentation lapses. The Treatment Plan Compliance Auditing Team will randomly audit Treatment Plans the 2nd Friday of each month based on regulation 709.92 and the agencies policy on treatment plan documentation. Findings from the audit will be analyzed and given to the Clinical Coordinators to review with counselors during weekly supervision sessions. Counselors identified as inadequate in treatment planning will receive additional support from the Clinical Coordinators. Counselors who fail to demonstrate improvement in the area of treatment planning despite additional support will be terminated no more than 60 days from the initial date deemed inadequate. Newly hired staff will not successfully pass orientation without demonstrating knowledge of the timelines for completing treatment plans and a clear understanding of how to clinically document the content of the treatment plan.
Correction Time: Complete
Monitoring: On-going
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of two records of clients who had been discharged from the project, the facility failed to document an aftercare plan in one record where required. Findings:On September 11, 2009, five client records were reviewed. Of the five records, two were for discharged clients, #4 and #5. Of the two discharged records, #4 did not require an aftercare plan. Record #5 indicated that the client had completed treatment, was discharged on 5/14/09, and there was no aftercare plan documented.
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Plan of Correction
In an effort to comply with regulation 709.93 (a)(9). During the clinical staff meeting scheduled for November 6, 2009, the Clinical Coordinators will distribute and review the Aftercare Plan Policy and Procedures with the Counselors emphasizing when the Aftercare Plan applies, when it should be developed and the content it must contain such as: identifying client's future goals for: sobriety, family/living situation, work/school, treatment involvement, medication management if applicable, cris, social developmental and etc. with timelines, method and frequency of continued contact, and criteria for re-entry. Aftercare Plans will be reviewed by the Clinical Coordinators prior to signing off and audited randomly at minimum every 120days based on regulation 709.93 ..., and the agencies policy on aftercare plans. Counselors identified as inadequate in aftercare planning will receive additional support from the Clinical Coordinator.
Correction Time: November 6, 2009 Monitoring On-going
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of two records of clients who had been discharged from the outpatient program, the facility failed to document a follow up contact in one record where required. Findings:On September 11, 2009, five client records were reviewed. Of the five records, two were for discharged clients, #4 and #5. Facility policy requires a follow up in 30 to 90 days by the primary counselor for clients who successfully complete treatment. Record #4 did not require a follow up as the client had not completed treatment. Record #5 required follow up contact as the client had completed treatment and was discharged on 5/14/09. There was no documentation of a follow up contact in record #5 as of 9/11/09.
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Plan of Correction
In an effort to comply with regulation 709.93 (a)(11). During the clinical staff meeting scheduled for November 6, 2009, the Clinical Coordinators will distribute and review the Aftercare Plan Policy and Procedures with the Counselors emphasizing when the Aftercare Plan applies, when it should be developed and the content it must contain such as: identifying client's future goals for: sobriety, family/living situation, work/school, treatment involvement, medication management if applicable, crisis, social developmental and etc. with timelines, method and frequency of continued contact/follow-up, and criteria for re-entry. Aftercare Plans will be reviewed by the Clinical Coordinators prior to signing off and audited randomly at minimum every 120days based on regulation 709.93 ..., and the agencies policy on aftercare plans. The chart review will focus on ensuring that Counselor's adhere to policy as it pertains to 30 to 90 days follow-up for all discharged Clients with an aftercare plan. Counselors identified as inadequate in aftercare planning and follow-up will receive additional support from the Clinical Coordinator.
Correction Time: November 6, 2009 Monitoring On-going
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