INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 21, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, GPHA Dental and Behavioral Health, was found to be not 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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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to notify the clients of the following with regard to client rights:(3) The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. (4) Clients have the right to appeal a decision limiting access to their records to the director. (5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Deficiency Noted:
709.30 (1) LICENSURE
Client rights:
§ 709.30. Client rights.
In an effort to meet and maintain compliance with regard to regulation 709.30 (1) Client Rights. Immediate action tool place to discard outdated Client Rights and Responsibility forms that had resurfaced at the facility.
Following the exit interview, a meeting was held with the clinical leadership team and site administrator to discuss in detail the findings from the survey. As a result of this meeting,
The correct Client Rights and Responsibility form was stocked at the site which includes but is not limited to: client's notification that: (1) The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
In addition, Active Clients will be asked to sign the correct Client's Rights and Responsibility form during their next scheduled visit effective June 22, 2018.
Monitoring Compliance: The site administrator will conduct at minimum weekly audits for 90-days to ensure compliance. The Clinical Coordinator will conduct random clinical chart audits at minimum by monthly for the first 90-days and monthly thereafter to ensure compliance with standard 709.30.
Data collected during these audits will be shared with the Clinical Leadership Team and QI Committee monthly to determine if additional corrective action strategies are needed to maintain compliance and/or if the deficiency has been successfully resolved.
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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 update the treatment plan every 60 days in two of two applicable client records.Client #4 was admitted on January 16, 2018 and discharged on June 18, 2018. A comprehensive treatment plan was documented on February 15, 2018; a treatment plan update was due by April 18, 2018 but was not documented until May 14, 2018.Client #5 was admitted on January 24, 2018 and discharged on June 3, 2018. A comprehensive treatment plan was documented on February 6, 2018; a treatment plan update was due by April 6, 2018 but was not documented until May 14, 2018.This information was reviewed with the facility staff during the licensing inspection.
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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 June 21, 2018, survey were reviewed by the Chief Behavioral Healthcare Officer, Director of Behavioral Health and Coordinator of Behavioral Healthcare Services immediately following the exit interview. As a result of the findings and full review of the cases found in non-compliance the following corrective action plan has been implemented.
A meeting was held on June 22, 2018, with the facility's Clinical Team 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 Preliminary/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
Monitoring: The Quality Assurance Clerk will conduct daily audits to ensure Treatment Plan time-lines are in compliance. Treatment Plans will be reviewed 2-days prior to a scheduled appointment to notify Counselors of potential non-compliance and 1-day following the scheduled appointment to ensure compliance was met and remains in good standing. The Clinical Supervisor will conduct weekly random reviews to ensure that all aspects of the treatment plan is in compliance with regards to standards 709.92.
TIME FRAME FOR COMPLETION:
June 25, 2018- Ongoing Monitoring
Evaluation of Monitoring Process
Every 60-days By Quality Assurance Manager and Clinical Coordinator
Data from the audits will be presented to the Clinical Leadership Team for review monthly and to the QI team as required.
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