INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 29, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Al-Assist Behavioral Healthcare Center 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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709.28(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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records on September 29, 2016, the facility failed to document an informed and voluntary consent in the following client records. Client #1 was admitted on 2/3/15 and was still an active client at the time of the inspection. A consent form to a funding source dated 6/22/16 permitted the release of the client's "plan of care/review, Medications prescribed, medical/physical history and psychosocial assessment", which exceeded 4 PA Code 255.5. Client #2 was admitted on 2/2/2016 and was still an active client at the time of the inspection. A consent form to a funding source dated 9/8/16 permitted the release of the clients "intake/admission information", which exceeded 4 PA Code 255.5. Client #3 was admitted on 4/4/16 and was still an active client at the time of the inspection. A consent form to a government agency dated 4/4/16 permitted the release of the clients "intake/admission information, psychiatric evaluation, Medications prescribed, medical/physical history, lab results, psychosocial assessment, progress notes, psychological evaluation and discharge summary", which exceeded 4 PA Code 255.5. Additionally, a consent form to a funding source dated 4/4/16 permitted the release of the same information as above except for the discharge summary.Client #4 was admitted on 4/7/2016 and was still an active client at the time of the inspection. A consent form to a consent form to a government agency dated 6/9/16 permitted the release of the clients "intake/admission information, psychiatric evaluation, Medications prescribed, medical/physical history, lab results, psychosocial assessment, progress notes, psychological evaluation and discharge summary", which exceeded 4 PA Code 255.5. Client #5 was admitted on 6/9/2016 and was still an active client at the time of the inspection. A consent form to a funding source dated 6/9/16 permitted the release of the clients "intake/admission information, psychiatric evaluation, Medications prescribed, medical/physical history, lab results, psychosocial assessment, progress notes, psychological evaluation and discharge summary", which exceeded 4 PA Code 255.5. Client #6 was admitted on 10/26/15 and was discharged on 5/4/16. A consent form to a funding source dated 1/28/16 permitted the release of the clients "intake/admission information, psychiatric evaluation, Medications prescribed, medical/physical history, lab results, psychosocial assessment, progress notes, psychological evaluation and discharge summary", which exceeded 4 PA Code 255.5. Client #7 was admitted on 10/14/15 and was discharged on 7/11/16. A consent form to a funding source dated 10/14/15 permitted the release of the clients "intake/admission information", which exceeded 4 PA Code 255.5. Client #8 was admitted on 3/7/16 and was discharged on 7/26/16. A consent form to a funding source dated 3/7/16 permitted the release of the clients "intake/admission information, psychiatric evaluation, Medications prescribed, medical/physical history, lab results, psychosocial assessment, progress notes, psychological evaluation and discharge summary", which exceeded 4 PA Code 255.5. Client #9 was admitted on 1/13/16 and was discharged on 7/4/16. A consent form to a government agency dated 1/19/16 permitted the release of the clients "intake/admission information, plan of care/review, lab results, discharge summary", which exceeded 4 PA Code 255.5. Client #10 was admitted on 12/15/15 and was discharged on 9/25/2016. A consent form to a funding source dated 12/15/15 permitted the release of the clients "intake/admission information", which exceeded 4 PA Code 255.5. This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
Standard in Noncompliance
709.28(c) LICENSURE CONFIDENTIALITY:
In an effort to regain and maintain full compliance with regulation 709.28 (c), the findings from the September 29, 2016, were reviewed by the Chief Behavioral Healthcare Officer, Director of Behavioral Health and Coordinator of Behavioral Healthcare Services. As a result of the findings and full review of the cases found in non-compliance the following corrective action plan has been implemented.
Informed and Voluntary consent templates that are available within our Electronic Health Record that exceeds the following:Confidentiality policy and procedures supportive of Standard 709.28(c) (2) /4 Pa code Subsection 255.5(b), will no longer be an available template/form selection for clients that are admitted into the Drug and Alcohol Program and/or Clients that are admitted into the Dual Diagnosed/Co-Occurring Program.
Clinical Staff will be limited to selecting an Informed and Voluntary Consent Template/Form for Clients admitted into the Drug and Alcohol Program and Dual Diagnosed/Co-Occurring Program that supports 709.28 (c) and specify the following: information to be released/disclosed 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, 709.28(c) LICENSURE CONFIDENTIALITY standards will be reviewed with the Clinical Team during the November's In-Service Training, facilitated by the Director of Behavioral Health and scheduled for November18, 2016.
Also, incorrect Informed and Voluntary Consent Templates/Forms that were previously used and signed by clients will be expired and replaced with the Correct Informed and Voluntary Consent Templates/Forms. For Example,
Clients #1,2,3,4,and 5 signed informed and voluntary consent form that were on file during the time of the audit that exceeded 4 PA Code 255.5 will be expired immediately and replaced with the correct informed and voluntary consent forms for the required continuity of care source, which is limited to 4 PA Code 255.5 during their next scheduled appointment.
Client #6, 7,8,9,and 10 signed informed and voluntary consent forms that was on file during the time of the audit will be expired immediately. No information will be released on these discharged clients unless we are able to contact the client when/if a continuity of care source contacts are agency for information and if and only if the Client is willing to come in and sign the correct Informed and Voluntary Consent form that is limited to 4 PA Code 255.5.
Informed and voluntary consent forms will be randomly audited bi-weekly for compliance by the Quality Assurance Department to ensure compliance. A random audit of each therapist caseload will be conducted periodically by the Clinical Coordinator to ensure that standard 709.28 (c)is being followed properly.
Correction Time: Correction In Progress with a targeted date of completion November 18, 2016 with Monitoring On-going |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records the facility failed to document a preliminary treatment and rehabilitation plan in the following records.Client #1 was admitted on 2/3/15 and was still an active client at the time of the inspection. Client #6 was admitted on 10/26/15 and was discharged on 5/4/16. Client #7 was admitted on 10/14/15 and was discharged on 7/11/16. This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
709.92(b) LICENSURE - TREATMENT AND REHABILITATION SERVICES
CORRECTIVE ACTION:
In an effort to regain and maintain full compliance with regulation 709.92 (b), the findings from the September 29, 2016, were reviewed by the Chief Behavioral Healthcare Officer, Director of Behavioral Health and Coordinator of Behavioral Healthcare Services. As a result of the findings and full review of the cases found in non-compliance the following corrective action plan has been implemented.
An urgent meeting has been scheduled for November 4, 2016, with the 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. The Clinical Supervisor will conduct weekly random reviews to ensure that all aspects of the treatment plan is in compliance with standard 709.92.
TIME FRAME FOR COMPLETION:
November 4, 2016- Ongoing Monitoring
Evaluation of Monitoring Process
Every 60-days By Quality Assurance Manager and Director of Behavioral Health
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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 client records the facility failed to document a comprehensive treatment and rehabilitation plan in the following records.Client #1 was admitted on 2/3/15 and was still an active client at the time of the inspection. No comprehensive treatment plan was documented. Client #4 was admitted on 4/7/2016 and was still an active client at the time of the inspection. A comprehensive treatment plan was not documented until 6/28/16, which is over two months after intake.Client #6 was admitted on 10/26/15 and was discharged on 5/4/16. A comprehensive treatment plan was not documented until 2/4/16, which is over three months after intake.Client #8 was admitted on 3/7/16 and was discharged on 7/26/16. No comprehensive treatment plan was documented. Client #10 was admitted on 12/15/15 and was discharged on 9/25/2016. A comprehensive treatment plan was not documented until 3/14/16, which is over three months after intake.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
709.92(b) LICENSURE - TREATMENT AND REHABILITATION SERVICES
CORRECTIVE ACTION:
In an effort to regain and maintain full compliance with regulation 709.92 (b), the findings from the September 29, 2016, were reviewed by the Chief Behavioral Healthcare Officer, Director of Behavioral Health and Coordinator of Behavioral Healthcare Services. As a result of the findings and full review of the cases found in non-compliance the following corrective action plan has been implemented.
An urgent meeting has been scheduled for November 4, 2016, with the 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. The Clinical Supervisor will conduct weekly random reviews to ensure that all aspects of the treatment plan is in compliance with standard 709.92.
TIME FRAME FOR COMPLETION:
November 4, 2016- Ongoing Monitoring
Evaluation of Monitoring Process
Every 60-days By Quality Assurance Manager and Director of Behavioral Health
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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 client records conducted on September 29, 2016, the facility failed to update the comprehensive treatment plan every 60 days in eight of ten client records.Client #1 was admitted on 2/3/15 and was still an active client at the time of the inspection. A treatment plan update was documented on 3/4/16, another update was due by 5/4/16 but was not documented until 5/17/16. The subsequent update was due by 7/17/16 but was not documented until 7/26/16.Client #2 was admitted on 2/2/2016 and was still an active client at the time of the inspection. A comprehensive treatment plan was documented on 1/8/16, a treatment plan update was due by 3/8/16 but was not documented until 4/20/16. Another update was documented on 7/6/16 but the subsequent update was not documented until 9/8/16.Client #3 was admitted on 4/4/16 and was still an active client at the time of the inspection. A comprehensive treatment plan was documented on 4/19/16; a treatment plan update was due by 6/19/16 but was not documented until 8/17/16. Client #4 was admitted on 4/7/2016 and was still an active client at the time of the inspection. A comprehensive treatment plan was documented on 6/28/16; a treatment plan update was due by 8/28/16 but was not documented at the time of the inspection. Client #5 was admitted on 6/9/2016 and was still an active client at the time of the inspection. A comprehensive treatment plan was documented on 7/7/16; a treatment plan update was due by 9/7/16 but was not documented at the time of the inspection. Client #6 was admitted on 10/26/15 and was discharged on 5/4/16. A comprehensive treatment plan was documented on 2/4/16; a treatment plan update was due by 4/4/16 but was not documented at the time of the inspection. Client #7 was admitted on 10/14/15 and was discharged on 7/11/16. A treatment plan update was documented on 1/12/16, another update was due by 3/12/16 but was not documented until 3/22/16. another treatment plan update was due by 5/22/16 but was not documented at the time of the inspection. Client #10 was admitted on 12/15/15 and was discharged on 9/25/2016. A treatment plan update was documented on 6/16/16, another update was due by 8/16/16 but was not documented until 8/24/16. This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
709.92(b) LICENSURE - TREATMENT AND REHABILITATION SERVICES
CORRECTIVE ACTION:
In an effort to regain and maintain full compliance with regulation 709.92 (b), the findings from the September 29, 2016, were reviewed by the Chief Behavioral Healthcare Officer, Director of Behavioral Health and Coordinator of Behavioral Healthcare Services. As a result of the findings and full review of the cases found in non-compliance the following corrective action plan has been implemented.
Client #4 has been officially administratively discharged due to an inability to actively engage the client in treatment.
Client #5 Treatment Plan has been updated bringing the chart into full compliance.
IN ADDITION:
An urgent meeting has been scheduled for November 4, 2016, with the 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. The Clinical Supervisor will conduct weekly random reviews to ensure that all aspects of the treatment plan is in compliance with standard 709.92.
TIME FRAME FOR COMPLETION:
November 4, 2016- Ongoing Monitoring
Evaluation of Monitoring Process
Every 60-days By Quality Assurance Manager and Director of Behavioral Health
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