INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 7, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Western Pennsylvania Counseling Services LLC dba Forge Health 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of six personnel records, the facility failed to ensure that four employees had a written individual training plan that was developed annually.
Employee # 1 was hired as the Facility Director on March 13, 2023 and was current in that position at the time of the inspection. Employee # 1 ' s initial annual individual training plan was not developed until October 23, 2023.
Employee # 3 was hired as a counselor on April 3, 2023 and was current in that position at the time of the inspection. Employee # 3 ' s initial annual individual training plan was not developed until October 23, 2023.
Employee # 4 was hired as a counselor on April 3, 2023 and was current in that position at the time of the inspection. Employee # 4 ' s initial annual individual training plan was not developed until October 23, 2023.
Employee # 5 was hired as a counselor on May 8, 2023 and was current in that position at the time of the inspection. Employee # 5 ' s initial annual individual training plan was not developed until October 23, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All new staff will have a training plan review scheduled within the first week of the onboarding process with Executive clinical director and will be coordinated by Human Resources. ECD and staff will review quarterly and review annually. |
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.
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Observations
Based on a review of client records and discussion with facility staff, the facility failed to complete an informed and voluntary consent to release information form to each client's funding source, prior to the disclosure of information, in all seven of seven applicable client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Education will be provided to clinicians in order to ensure that ROI consents are completed and on file during the intake process. Executive clinical director will pull charts for auditing to ensure complete intake documentation is present, use clinical rounds and supervision to review chart documentation. All current active clients in the census will be updated with ROI's for insurance providers |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in three of four applicable client records reviewed.
Client # 2 was admitted on June 22, 2023 and was discharged on October 23, 2023. The individual treatment and rehabilitation plan was completed on June 30, 2023; however, the plan did not include documentation of the proposed type of support services.
Client # 5 was admitted on May 19, 2023 and was discharged on September 6, 2023. The individual treatment and rehabilitation plan was completed on May 25, 2023; however, the plan did not include documentation of the proposed type of support services.
Client # 7 was admitted on October 12, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 3, 2023; however, the plan did not include documentation of the proposed type of support services.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Training will be provided to staff by the Executive Clinical Director to identify and appropriately document supportive services that clients are actively engaged in as well as utilizing care coordinator to offer support and connection to services that support recovery and relapse prevention for IOP an co-occurring OP clients. Executive clinical director will ensure during supervision within 7 days that supportive services are documented and/or explored. |
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 client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed updated at least every 60 days in two of four applicable records reviewed.
Client # 1 was admitted on July 25, 2023 and was discharged on November 30, 2023. The individual treatment and rehabilitation plan was completed on August 10, 2023 and the treatment plan update was due to be completed by October 10, 2023; however, no treatment plan updates were completed prior to the client ' s discharge.
Client # 6 was admitted on September 11, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on October 4, 2023 and the treatment plan update was due to be completed by December 4, 2023; however, no treatment plan updates were completed prior to the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive clinical director will review proper treatment plan procedures with clinical Team during weekly clinical rounds. Executive clinical director will also review in individual supervision. Executive clinical director will randomly pull chart to audit and ensure Outpatient treatment Plans are being updated every 60 days. |
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.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information within seven of admission and every 90 days thereafter, per facility policy, in five of six applicable records reviewed.
Client # 2 was admitted on June 22, 2023 and was discharged on October 23, 2023. The first case consultation note was due to be completed by June 29, 2023; however, it was not documented until August 15, 2023.
Client # 3 was admitted on May 17, 2023 and was discharged on July 26, 2023. The first case consultation note was due to be completed by May 24, 2023; however, there was no documentation that a case consultation occurred by the time of the client ' s discharge.
Client # 5 was admitted on May 19, 2023 and was discharged on September 6, 2023. A case consultation was due by May 26, 2023; however, it was not documented until July 25, 2023.
Client # 6 was admitted on September 11, 2023 and was active at the time of the inspection. The first case consultation note was due to be completed by September 18, 2023; however, there was no documentation that a case consultation occurred prior to the date of the inspection.
Client # 7 was admitted on October 12, 2023 and was active at the time of the inspection. A case consultation was due by October 19, 2023; however, it was not documented until November 21, 2023.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Executive clinical director will initiate plan of correction. The Office manager and Executive clinical director will be taking minutes and recording each clinical rounds meeting in which co-occurring substance use disorder and intensive outpatient clients are discussed. Individual supervision notes will reflect case consultation with Executive Clinical Director within 7 days and again 90 days thereafter. Supervision notes will be stored individually by clinician, in a timely manner.
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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 a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan, in three of three applicable records reviewed.
Client # 1 was admitted on July 25, 2023 and was discharged on November 30, 2023. The client record did not contain documentation of a completed aftercare plan.
Client # 2 was admitted on June 22, 2023 and was discharged on October 23, 2023. The client record did not contain documentation of a completed aftercare plan.
Client # 5 was admitted on May 19, 2023 and was discharged on September 6, 2023. The client record did not contain documentation of a completed aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive clinical director will use individual supervision and clinical rounds for case consultation to ensure clients will have a relapse prevention plan developed with and provided to the client before discharge from IOP and/or SUD/OP level of care |
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 client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in three of four applicable records reviewed. The facility policy is to complete a follow up within 30, 60, and 90 days of discharge.
Client # 3 was admitted on May 17, 2023 and was discharged on July 26, 2023. The client record did not contain documentation of follow-up information.
Client # 5 was admitted on May 19, 2023 and was discharged on September 6, 2023. The first follow-up was due to occur by October 6, 2023; however, it was not documented until October 12, 2023. The record did not contain documentation of 60-day follow-up information.
Client # 3 was admitted on February 7, 2023 and was discharged on May 9, 2023. The client record did not contain documentation of follow-up information.
Client # 8 was admitted on July 14, 2023 and was discharged on August 11, 2023. The client record did not contain documentation 60- or 90-day follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Clinical Director will review and revise existing Follow-Up policy to add specifics of staff responsibility. Staff will be trained to follow up 30-, 60- and 90-days post discharge from substance use, co-occurring or intensive outpatient level of treatment. The Executive Clinical Director will train all staff to comply with updated Follow-Up policy. Executive Clinical Director to randomly pull chart audits to ensure policy is being followed". |