INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 3, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of client records, the facility failed to ensure that treatment plans are reviewed and updated at least every 60 days in five of seven client records reviewed.Client #1 was admitted March 16, 2021 and was active at the time of inspection. A treatment plan update was completed on July 1, 2022 and the next update was due no later than September 1, 2022. However, the update was not completed at the time of the inspection. Client #2 was admitted July 6, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on July 6, 2022 and an update was due no later than September 6, 2022. However, the update was not completed at the time of the inspection.Client# 5 was admitted March 2, 2022 and was discharged September 20, 2022. The comprehensive treatment plan was completed on March 7, 2022 and an update was due no later than May 7, 2022. However, the update was not completed prior to discharge.Client # 6 was admitted November 9, 2021 and was discharged June 1, 2022. The comprehensive treatment plan was completed on November 11, 2022 and an update was due no later than January 11, 2022. However, the update was not completed prior to discharge.Client # 7 was admitted October 14, 2021 and was discharged March 29, 2022. The comprehensive treatment plan was completed on October 14, 2021 and an update was due no later than December 28, 2021. However, the update was not completed prior to discharge.The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
709.92 (b) ? Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
Effective immediately, the Counselors and Clients will be required to have an onsite face-to-face visit between the fiftieth and fifty-eight days of a treatment plan update. The counselor will review daily treatment plan audits provided by the Quality Assurance Department and prepare to schedule onsite visits and update treatment plans. Counselors must complete the treatment plan update regardless of the Client's attendance or participation. Clients who fail to keep their scheduled appointment before the required update will be instructed to review the treatment plan update at their next appointment. No adjustments to the existing plan will be made to avoid an automatic electronic submission date change in the EHR record. Client comments regarding the treatment plan will be documented in the progress note. If the Client disagrees with the completed treatment plan update, a new treatment plan update will be developed to accommodate the recommended changes and agreed-upon treatment.
Ongoing monitoring of compliance.
The QA Department will reconcile the treatment plan audits weekly to identify treatment plan update completion and those in need of completion.
Clinical Supervisors will monitor the quality assurance reports for compliance. Clinical Supervisors will review completed treatment plans for compliance weekly.
The Site Director will be responsible for ongoing monitoring of the Clinical Supervisors to ensure the treatment plan audit reports are being reviewed and client records are in compliance with standard 709.92 (b).
The QA Manager will audit treatment rehabilitation plans for compliance and report on the aggregate findings per counselor, per location, monthly and quarterly.
Additionally, training and support will be provided to counselors as needed.
|
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on the review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in four of seven client records reviewed. Client #1 was admitted March 16, 2021 and was active at the time of inspection. The treatment and rehabilitation plan, dated July 1, 2022, indicated that the client was to receive bi-weekly individual sessions. There was no documentation in the record of any individual sessions or group sessions provided to the client since July 1, 2022.Client# 5 was admitted March 2, 2022 and was discharged September 20, 2022. The treatment and rehabilitation plan, dated March 7, 2022, indicated that the client was to receive bi-weekly individual sessions. There was no documentation in the record of any individual sessions or group sessions provided to the client since March 7, 2022.Client # 6 was admitted November 9, 2021 and was discharged June 1, 2022. The treatment and rehabilitation plan, dated November 9, 2021, indicated that the client was to receive bi-weekly individual sessions. There was no documentation in the record of any individual sessions provided to the client since November 9, 2021.Client # 7 was admitted October 14, 2021 and was discharged March 29, 2022. The treatment and rehabilitation plan, dated October 14, 2021, indicated that the client was to receive bi-weekly individual sessions. There was no documentation in the record of any individual sessions provided to the client since October 14, 2021.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
709.92 (c) ? The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
In an effort to reestablish and maintain compliance as it relates to Standard 709.92 (c), the following corrective action plan has been put in place.
The Counselor and client will meet to discuss the counseling services to be provided in their individual treatment and rehabilitation plan. Counselor will ensure that services are rendered as indicated and agreed upon in the treatment and rehabilitation plan, and document accordingly. Counselor will document all services in accordance with the individual's treatment and rehabilitation plan, whether the client attends or fails to attend. If client is unable to meet the agreed upon schedule of services in accordance with the treatment and rehabilitation plan, Counselor and client will update the treatment and rehabilitation plan to an agreed upon course of treatment.
Ongoing monitoring of compliance.
Clinical Supervisors will provide bi-weekly supervision to Counselors to ensure an understanding of Compliance with 709.92 (c). Clinical Supervisors will audit charts and review treatment plans weekly to ensure compliance with 709.92 (c).
The Site Director will be responsible for ongoing monitoring of the Clinical Supervisors to ensure that counseling services are provided according to the individual's treatment and rehabilitation plan.
QA will audit treatment and rehabilitation plans to assess the accuracy and compliance of treatment frequency and agreed upon services and supported documentation. Results will be presented during the monthly all staff meeting and site leadership meeting.
Additionally, training interventions and support will be provided to counselors as needed to bring the accuracy of treatment and rehabilitation planning to an acceptable compliance of 100%..
|
709.93(a)(5) 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:
(5) Progress notes.
|
Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include progress notes, in four of seven client records reviewed.Client# 3 was admitted August 10, 2022 and was active at the time of inspection. Client# 4 was admitted September 9, 2021 and was discharged September 20, 2022Client# 5 was admitted March 2, 2022 and was discharged September 20, 2022.Client # 6 was admitted November 9, 2021 and was discharged June 1, 2022.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
709.93 (a)(5) ? 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: (5) Progress notes.
In an effort to reestablish and maintain compliance as it relates to Standard 709.93 (a)(5), the following corrective action plan has been put in place. 709.93 (a)(5) regulation will be reviewed with the clinical team on Friday, October 28, 2022, to reiterate regulations regarding progress note documentation.
The Counselor will be required to document a progress note in the client record for every service scheduled, according to the client's involvement with the project. A progress note must be written by the Counselor regardless of whether or not the client is present, cancels, or fails to show for the scheduled visit. The Counselor will review daily schedule to ensure that clinical documentation has been submitted for each scheduled service. Outreach efforts for clients who failed to keep their scheduled appointment and documentation of outreach and/or rescheduled appointment in their progress note.
Ongoing monitoring of compliance.
The QA Department will monitor the Counselor's daily client schedule to verify completion of documentation of the client's involvement with the project for each scheduled session. The QA Department will provide notification of compliance to Counselors and Clinical Supervisors.
Clinical Supervisors will monitor the Counselor's daily client schedule to ensure completion of documentation of the client's involvement with the project for each scheduled session. The Clinical Supervisor will review compliance with standard 709.93 (a)(5) during bi-weekly supervision meetings.
The Site Director will be responsible for ongoing monitoring of the Clinical Supervisors to ensure the client record includes the client's involvement in the project for each scheduled session.
Additionally, training and support will be provided to counselors as needed to ensure continued compliance.
|
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 document a complete client record, which is to include case consultation notes, in four of seven client records reviewed.Client# 4 was admitted September 9, 2021 and was discharged September 20, 2022Client# 5 was admitted March 2, 2022 and was discharged September 20, 2022.Client # 6 was admitted November 9, 2021 and was discharged June 1, 2022.Client # 7 was admitted October 14, 2021 and was discharged March 29, 2022.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
709.93 (a)(8) ? There shall be a complete client record on an individual which includes information relative to the client's involvement with the project.
CLIENT RECORD
In an effort to reestablish and maintain compliance as it relates to Standard 709.93 (a)(8), the following corrective action plan has been put in place.
An in-service review of the Case Consultation policy and standard 709.93 (a)(8), has been added to the scheduled in-service for October 21, 2022. During this in-service, staff will be given a pre/post-test of the regulations and protocol. Training emphasis will be placed on the following: The Purpose of Conducting Case Consultations, Case Consultation Timelines, Electronic Form Completion, Recording the Treatment Recommendations Electronically during the Case Consult and Obtaining Signatures of Participants. All newly hired clinical staff will receive this training during orientation.
Failure of the post-test will require 1-1 support from the assigned Supervisor and a retaking of the post-test.
In addition, the development of a case consultation compliance report (tool) has been requested from the IS/EHR Specialist. Upon completion of the requested report, Counselors and Supervisors will be able to monitor case consultation due dates and recommendations with accuracy.
Monitoring of Case Consultation Compliance will be completed monthly by the quality control clerks.
Content and compliance will be randomly monitored by the Site Directors at minimum by monthly.
The monitoring process will be reviewed quarterly by the QA Department to ensure compliance. Findings from this review will be shared during the Leadership meeting for additional strategies to improve the process if needed.
Monitoring On-going
|