INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 8, 2023 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:
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel files, the facility failed to ensure each counselor met the educational and/or the experiential qualifications in one of one applicable personnel record reviewed.Employee #4 was hired as a counselor on December 19, 2022. The employee does possess the required bachelor ' s degree with a major in a related field; however, the employee did not have the required one year of clinical experience prior to being hired.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
704.7(b) LICENSURE
In an effort to comply with 704.7(b) the employee identified as not meeting the required one-year clinical experience prior to hire employment status has changed to a counselor assistant. The employee is under the close supervision of a clinical supervisor and will maintain close supervision over the next 6 months. The employee will remain as a bachelor's level counselor assistant until obtaining 1-year of experience in the field of addiction treatment. The employee's development plan will continue to focus on achieving counseling competency in chemical dependency issues.
Correction: Completed
On-going Monitoring:
The Site Director and Clinical Supervisor will provide close supervision over the employee monitoring assigned cases to ensure guidance and feedback is provided. Documentation of the close supervision will be maintained electronically for random audits from the QA Department.
The Program Director will review the resume of potential hires to ensure that no new hire is placed in a role that fails to meet the educational or experience requirements.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the policy and procedure manual and client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in two of four applicable client records reviewed.The policy and procedure manual stated that the program will complete a discharge summary within 7 days of discharge.Client #5 was admitted on January 26, 2023 and was discharged on April 27, 2023. The discharge summary was due no later than May 4, 2023; however, the summary was completed on June 14, 2023.Client #6 was admitted on March 24, 2023 and was discharged on May 11, 2023. The discharge summary was due no later than May 18, 2023; however, the summary was completed on June 15, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
In an effort to comply with 709.93(a)(10) Discharge summary. The following corrective action plan has been revitalized and updated considering staff turnover, hybrid employees, and new hires.
Effective July 10, 2023, the Admissions and Discharge Dept. "AD Dept." began generating and monitoring last date of service reports daily to ensure members loss to care are discharged on day 30 and/or at the end of business day Friday-if member's date of discharge falls on the weekend.
AD Dept. will initiate discharge and discharge notation for members identified out-of-compliance and notify Clinical Supervisors in writing that a written discharge summary and supporting fields is needed for members who participated in services more than three (3) times with an identified Counselor. AD Dept. will initiate and complete discharge in its entirety for members who failed to complete the intake process and/or return after the intake process.
Correction: Completed
Monitoring On-going
Discharged Members are identified on the DA Post-Discharge Tracker. AD Dept. will update and maintain tracker daily based on generated Key Performance reports in the EHR system. AD Manager will monitor Clinical Supervisors and Counselor to ensure discharge summary is completed within seven (7) days of notification.
Clinical Supervisors will instruct Counselor to complete discharge summary and required fields no later than day seven (7) post-discharge. Upon completion, AD Dept. will update Post-Discharge Tracker to identify clinicians' compliance per regulations.
Clinical Supervisors are responsible for notifying Counselor when an discharge summary is due and obligated to ensure that Counselors are completing discharge summary and supporting fields in a timely manner.
The AD Manager is responsible for monitoring this process and reporting the final results to the BH Leadership Team during monthly Meetings. Moving forward the AD Manager will Monitor Compliance weekly and consult with the Site Director and Clinical Supervisor to ensure discharge summary are meeting compliance prior to the monthly report.
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709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in two of eight client records reviewed.Client #6 was admitted on March 24, 2023 and discharged on May 11, 2023. A release of information form to a primary care physician was signed and dated by the client on March 24, 2023; however, the name of the physician, agency or organization was not documented on the release form. Client #7 was admitted on March 10, 2023 and discharged on July 29, 2023. A release of information form to a primary care physician was signed and dated by the client on March 10, 2023; however, the name of the physician, agency or organization was not documented on the release form. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
In an effort to comply with Standard 709.28(d) Confidentiality (c) (1) at minimum the Name of the person, agency or organization to whom disclosure is made must be documented on the consent form:
To avoid human errors of not completing the entire consent form. All fields are now required and must be completed prior to submitting the form electronically.
Furthermore, a Category field has been added to the consent form which includes but is not limited to: Health Plan, PCP, Laboratories, Emergency Contact, Court System, Probation Officer, Recovery/Residential Program, School/University, Employer, Family Member.
Adding the category field forces employees to select the category for disclosure type. However, presents the need for further explanation as to the name of the person, agency, or organization to whom the disclosure is being made.
Correction: Completed
Monitoring: On-going
AD Dept. and Clinical supervisors will review completed intakes on a weekly basis during scheduled Admission and Discharge Committee meetings to ensure that documentation particularly consents are completed according to standards and within regulatory guidelines.
The supervisors will also review authorizations during biweekly supervision meetings with urgent care providers and report findings back to Site director,
bi-weekly.
Site director will monitor clinical supervisors' accountability and progress in ensuring staff complete all required intake paperwork efficiently and according to regulations, policies, and procedures.
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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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be released on consent to release information forms in one of eight client records reviewed. Client #1 was admitted on January 10, 2023 and was active at the time of the inspection. There were release of information forms to the funding source and the urinalysis laboratory that were signed and dated by the client on January 10, 2023; however, the specific information to be disclosed was not documented on either release form. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
709.28 (c) (2) LICENSURE
Confidentiality:
In an effort to comply with § 709.28. Confidentiality. During a recent tracer regarding non-compliance with 709.28 (c) (2), we discovered a bypass/ glitch in our ERH system and made the following correction.
The Program type field was made a required field as well, which enforces § 709.28 full compliance. Changing this field to required blocks counselors from submitting the form without completing all required fields which supports the confidentiality release of information guidelines.
Active clients informed and voluntary consent forms are under review. Active Clients without specific information to be released on consents will be asked to review, approve, and sign an updated consent form to specific information to disclose.
Correction: Completed
Ongoing monitoring-
DA Clinical Supervisors/Coordinators will monitor active Clients over the next 30-days to ensure all informed and voluntary consent forms are in compliance. The Admission and Discharge Manager will perform bi-weekly audits of new admits ensuring that the informed and voluntary consent forms are completed according to standards. Findings from the audit will be presented quarterly to the BH Leadership Team
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709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of client on a release of information form in one of eight client records reviewed. Client #1 was admitted on January 10, 2023 and was active at the time of the inspection. There was a release of information form to a urinalysis laboratory that was signed and dated by the witness on January 10, 2023; however, the dated signature of the client was not documented on the release form.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
To comply with Standard 709.28 (c) (4) Confidentiality dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
The signature field was made a required field in the electronic health record in July 2023, to avoid human errors of not completing the entire consent form. All fields are now required and must be completed prior to submitting the form electronically.
Correction: Completed
Monitoring: On-going
AD Dept. and Clinical supervisors will review completed intakes on a weekly basis during scheduled Admission and Discharge Committee meetings to ensure that documentation particularly consents are completed according to standards and within regulatory guidelines.
The supervisors will also review authorizations during biweekly supervision meetings with urgent care providers and report findings back to Site director, biweekly.
Site director will monitor clinical supervisors' accountability and progress in ensuring staff complete all required intake paperwork efficiently and according to regulations, policies, and procedures.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that that a copy of a consent to release information form was offered to the client in six of eight client records reviewed.Client #1 was admitted on January 10, 2023 and was active at the time of inspection. There were release of information forms to a funding source, a urinalysis laboratory, a physician, and an emergency contact that were signed and dated by the client on January 10, 2023; however, there was no documentation that a copy of any of the release forms were offered to the client. Client #3 was admitted on February 23, 2023 and was active at the time of inspection. There was a release of information form to probation and parole that was signed and dated by the client on May 11, 2023; however, there was no documentation that a copy of the release form was offered to the client. Client #4 was admitted on March 16, 2023 and was active at the time of inspection. There were release of information forms to a funding source, a urinalysis laboratory, a physician, and an emergency contact that were signed and dated by the client on March 16, 2023; however, there was no documentation that a copy of any of the release forms were offered to the client. Client #6 was admitted on March 24, 2023 and was discharged on May 11, 2023. There were release of information forms to a funding source, a urinalysis laboratory, a physician, and an emergency contact that were signed and dated by the client on March 24, 2023; however, there was no documentation that a copy of any of the release forms were offered to the client. Client #7 was admitted on March 10, 2023 and was discharged on July 29, 2023. There were release of information forms to a funding source, a urinalysis laboratory, a physician, and an emergency contact that were signed and dated by the client on March 10, 2023; however, there was no documentation that a copy of any of the release forms were offered to the client. Client #8 was admitted on April 24, 2023 and was discharged on August 2, 2023. There was a release of information form to a court that was signed and dated by the client on April 24, 2023; however, there was no documentation that a copy of the release form was offered to the client. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
In an effort to comply with Standard 709.28(d) Confidentiality (d) A copy of a client consent shall be maintained in the record.
In an effort to comply with 709.28(d) written notification of offering the client a copy of their consent form is now a required field on the consent form to avoid careless human errors of not completing the entire consent form. All fields must be completed prior to submitting the form Electronically.
Correction: Completed
Monitoring: On-going
AD Dept. and Clinical supervisors will review completed intakes on a weekly basis during scheduled Admission and Discharge Committee meetings to ensure that documentation particularly consents are completed according to standards and within regulatory guidelines.
The supervisors will also review authorizations during biweekly supervision meetings with urgent care providers and report findings back to Site director,
bi-weekly.
Site director will monitor clinical supervisors' accountability and progress in ensuring staff complete all required intake paperwork efficiently and according to regulations, policies, and procedures. |
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 are reviewed and updated at least every sixty days in five of five applicable client records reviewed.Client #1 was admitted on January 10, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on January 10, 2023, and the first update was due no later than March 10, 2023; however, the update was completed on April 26, 2023. Additionally, the next treatment plan update was due no later than June 26, 2023; however, the update was completed on July 7, 2023.Client #2 was admitted on February 7, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on March 3, 2023, and the first update was due no later than May 3, 2023; however, the update was completed on June 28, 2023. Client #3 was admitted on February 23, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on March 2, 2023, and the first update was due no later than May 2, 2023; however, the update was completed on May 19, 2023. Client #4 was admitted on March 16, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on March 30, 2023, and the first update was due no later than May 30, 2023; however, the update was completed on June 5, 2023. Additionally, the next treatment plan update was due no later than August 5, 2023; however, the update was not completed at the time of inspection.Client #7 was admitted on March 10, 2023 and was discharged on July 29, 2023. The individual treatment and rehabilitation plan was completed on March 28, 2023, and the first update was due no later than May 28, 2023; however, the update was completed on June 22, 2023 This is a repeat citation from the October 3, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
In an effort to comply with Standard 709.92(b) Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
Clinical Supervisors will monitor the DA Compliance Tracker weekly to identify Members with Treatment and Rehabilitation Plans that are approaching the 60-day review date and coordinate the due date in advance with the Counselor and Member.
Treatment and Rehabilitation Plans for Drug and Alcohol members will no longer be driven by regularly scheduled appointments but developed and processed based on the treatment and rehabilitation plan update due date. All efforts will be made to coordinate with the members in advance to obtain input and signatures.
Treatment and Rehabilitation Updates will be finalized electronically every 60-days providing day 60 falls on a workday. In the event of day 60 falling outside of a scheduled workday, the Treatment and Rehabilitation Plan will be finalized within 24 hours of the scheduled Treatment and Rehabilitation Plan Update due date.
An addendum to information in the Treatment and Rehabilitation Plans may occur after the finalized Treatment and Rehabilitation Plan Update at the request of the Member, Counselor, or Clinical Supervisory Team.
Information regarding Treatment and Rehabilitation Plan Addendum and Finalization Process was added to the Treatment and Rehabilitation Plan Policy and reviewed with the Policy and Procedure Sub-Committee on Friday, July 7, 2023.
ALL Clinical Staff received a copy of the revised policy with the revisions highlighted on Monday, July 10, 2023. Formal training of the revision took place on July 18, 2023. The changes and expectations are actively being discussed during supervision sessions.
Correction: Completed
On-going Monitoring:
Supervisors will monitor treatment and rehabilitation plans weekly using the DA tracker to identify upcoming Treatment and Rehabilitation Plans that are due for a 60-day Update until the member has satisfied the requirements for program discharge.
The QA Department will continue to reconcile the treatment and rehabilitation plan audits weekly to identify treatment plan update completion and those in need of completion based on scheduled appointments.
The Site Director will be responsible for weekly monitoring of the Clinical Supervisors compliance with tracking DA services and to ensure that quality services are being provided based on the level of care and treatment outlined in the treatment and rehabilitation plan.
The QA Manager will audit treatment and rehabilitation plans for compliance with 709.92 (b) and for clinical soundness. Aggregate findings per location, per supervisor, per counselor will be reported to the BH Leadership Team Monthly and Quarterly to the Executive Staff. The purpose of pulling aggregate data on each site and employees is to identify gaps in care and to identify if additional training is need on a site level or individual level.
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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.
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Observations
Based on a 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 five applicable client records reviewed. Client #1 was admitted on January 10, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan, dated January 10, 2023, indicated biweekly individual counseling services. There was no documentation of individual counseling services occurring during the weeks of February 5, 2023 - April 15, 2023.Client #3 was admitted on February 23, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan, dated March 2, 2023, indicated biweekly individual counseling services. There was no documentation of individual counseling services occurring during the weeks of April 2, 2023 - April 29, 2023.Client #4 was admitted on March 16, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan dated March 30, 2023, indicated biweekly individual counseling services. There was no documentation of individual counseling services occurring during the weeks of April 2, 2023 - April 15, 2023.Client #5 was admitted on March 10, 2023 and was discharged on July 29, 2023. The individual treatment and rehabilitation plan, dated March 28, 2023, indicated biweekly individual counseling services. There was no documentation of individual counseling services occurring during the weeks of April 23, 2023 - May 20, 2023.This is a repeat citation from the October 3, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
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.
To comply with 709.92. (c) Treatment and rehabilitation services, the following measures have been put in place to ensure that counseling services are provided according to the individual treatment and rehabilitation plan.
Clinical Supervisors will ensure that frequency of individual and group sessions are added to the DA tracker to monitor treatment scheduling compliance based on the proposed treatment frequency. The clinical supervisor will monitor the DA Tracker weekly to ensure compliance of treatment frequency.
Clinical Counselors who fail to schedule according to the proposed treatment frequency will be reminded immediately of the need to schedule appointments as outlined in the approved treatment and rehabilitation plan.
Members who are scheduled according to the proposed treatment frequency and fail to attend the scheduled treatment session will receive follow-up to identify the causal factor(s) for the missed appointment and to reschedule the missed appointment. If the member continues to miss scheduled appointment despite efforts to encourage full treatment participation, an addendum to the treatment and rehabilitation plan will be made to align with the Members current ability to actively participate in treatment.
Correction: Completed
On-going Monitoring:
Supervisors will monitor treatment and rehabilitation plan (treatment frequency) weekly using the DA tracker to identify scheduling and participation compliance with Treatment and Rehabilitation Plan identified treatment frequency.
The Site Director will be responsible for weekly monitoring of the Clinical Supervisors compliance with tracking DA services and to ensure that quality services are being provided based on the level of care, treatment frequency, and treatment outlined in the treatment and rehabilitation plan.
The Site Director will be responsible for reporting on the findings of the DA Tracker in monthly site meetings. Aggregate findings will be reported to identify gaps in care and to identify if additional training is needed on a site level or individual level. |