INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 1, 2025 through April 2, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Beyond Addiction Recovery and Treatment Center, LLC. 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of five personnel records, the project failed to ensure that a clinical supervisor that has not functioned for two years as a supervisor in the provision of clinical services complete a core curriculum in clinical supervision.
Employee #2 was hired as a clinical supervisor on July 16, 2024, and was current in that position at the time of the inspection. Employee #2 had not functioned for two-years as a supervisor in the provision of clinical services and as of the time of the inspection had not completed a core curriculum in clinical supervision.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
**Deficiency Addressed**
Beyond Addiction identified deficiencies in the hiring and training of staff necessary to maintain compliance with DDAP regulations. These included gaps in verifying qualifications, conducting appropriate training based on skill level and job role, and ensuring ongoing compliance tracking.
### **Corrective Action Plan**
#### **1. Leadership Accountability**
- **As of 4/21/2025**, the **Clinical Supervisor** has successfully completed the **DDAP-accepted Core Curriculum** for the Clinical Supervisor position, affirming eligibility to oversee clinical staff and training.
- The **Chief of Staff Development** has been officially appointed to oversee **all hiring practices**, effective **4/21/2025**.
#### **2. Hiring Practices**
**Responsible Party:** Chief of Staff Development
**Actions:**
- Implement a **standardized hiring protocol** which includes:
- Verification of educational credentials and professional licenses.
- Completion of comprehensive background checks.
- Review of professional experience to ensure role-appropriate qualifications.
- Verification that all prospective staff meet DDAP criteria for their position prior to hiring.
- Establish a **centralized candidate tracking system** to document all screening activities and decision rationales for future audits.
- Maintain documentation of DDAP qualifications for each role and update staff files annually.
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#### **3. Training and Credential Verification**
**Responsible Parties:** Clinical Supervisor & Chief of Staff Development
**Actions:**
- All staff training will be **tailored to skill level, job description, and DDAP requirements.**
- The Clinical Supervisor will:
- Assess staff training needs based on DDAP regulations and individual performance reviews.
- Ensure that all clinical personnel receive training in DDAP Core Curriculum areas (e.g., confidentiality, ethics, clinical documentation, treatment planning).
- Maintain documentation of all trainings completed, including agendas, attendance logs, and evaluations.
- Chief of Staff Development will:
- Maintain an annual **training schedule and compliance tracker**, ensuring all staff complete mandatory training within specified timeframes.
- Conduct quarterly audits of staff training records.
- The Chief of Staff is required to monitor and maintain all required training and training hours based on the employee's function. The DDAP orientation requirements and trainings will be completed within the regulatory time frame. Chief of staff will keep training logs for all employees.
Chief Executive Officer will oversee and monitor the completion and logs based on the Chief of Staff's training documentation monthly.
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#### **4. Monitoring and Continuous Improvement**
**Responsible Party:** Chief of Staff Development
**Actions:**
- Implement **quarterly internal audits** of hiring and training compliance using a DDAP-aligned checklist.
- Establish a **Corrective Action Review Committee** (Clinical Supervisor, Chief of Staff Development, Executive Director) to:
- Review audit findings.
- Implement remediation within 15 days of deficiency detection.
- Report to DDAP if required.
- All policies and procedures regarding hiring and training will be reviewed **biannually** and updated as needed to reflect DDAP regulatory changes.
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### **Supporting Documentation**
- Staff roster with credentials and dates of DDAP compliance
- Training calendar and attendance records
- Hiring protocol and applicant screening checklist
- DDAP compliance checklist for supervisory review
- Quarterly audit reports and corrective action logs
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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 the review of personnel records, the project failed to document a written initial individual training plan for each employee, appropriate to that employee's skill level with input from both the employee and the supervisor in one out of five records reviewed.
Employee #4 was hired on December 16, 2024, and was to have an initial individual training plan documented by January 16, 2025; however, at the time of the inspection, the date the training plan was developed was not documented and it was also not documented whether the employee and supervisor both provided input.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The **Chief of Staff Development** has been officially appointed to oversee **all hiring practices**, effective **4/21/2025**.
#### **2. Hiring Practices**
**Responsible Party:** Chief of Staff Development
**Actions:**
- Implement a **standardized hiring protocol** which includes:
- Verification of educational credentials and professional licenses.
- Completion of comprehensive background checks.
- Review of professional experience to ensure role-appropriate qualifications.
- Verification that all prospective staff meet DDAP criteria for their position prior to hiring.
- Establish a **centralized candidate tracking system** to document all screening activities and decision rationales for future audits.
- Maintain documentation of DDAP qualifications for each role and update staff files annually.
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#### **3. Training and Credential Verification**
**Responsible Parties:** Clinical Supervisor & Chief of Staff Development
**Actions:**
- All staff training will be **tailored to skill level, job description, and DDAP requirements.**
- The Clinical Supervisor will:
- Assess staff training needs based on DDAP regulations and individual performance reviews.
- Ensure that all clinical personnel receive training in DDAP Core Curriculum areas (e.g., confidentiality, ethics, clinical documentation, treatment planning).
- Maintain documentation of all trainings completed, including agendas, attendance logs, and evaluations.
- Chief of Staff Development will:
- Maintain an annual **training schedule and compliance tracker**, ensuring all staff complete mandatory training within specified timeframes.
- Conduct quarterly audits of staff training records.
- The Chief of Staff is required to monitor and maintain all required training and training hours based on the employee's function. The DDAP orientation requirements and trainings will be completed within the regulatory time frame. Chief of staff will keep training logs for all employees.
Chief Executive Officer will oversee and monitor the completion and logs based on the Chief of Staff's training documentation monthly.
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#### **4. Monitoring and Continuous Improvement**
**Responsible Party:** Chief of Staff Development
**Actions:**
- Implement **quarterly internal audits** of hiring and training compliance using a DDAP-aligned checklist.
- Establish a **Corrective Action Review Committee** (Clinical Supervisor, Chief of Staff Development, Executive Director) to:
- Review audit findings.
- Implement remediation within 15 days of deficiency detection.
- Report to DDAP if required.
- All policies and procedures regarding hiring and training will be reviewed **biannually** and updated as needed to reflect DDAP regulatory changes.
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### **Supporting Documentation**
- Staff roster with credentials and dates of DDAP compliance
- Training calendar and attendance records
- Hiring protocol and applicant screening checklist
- DDAP compliance checklist for supervisory review
- Quarterly audit reports and corrective action logs
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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 client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one applicable record reviewed.
Client #5 was admitted to the inpatient non-hospital level of care on February 5, 2025 and was discharged Against Staff Advice (AMA) on February 28, 2025. The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Chief Clinical Officer will ensure that all clients who are considered AMA/Administrative Discharges will have their emergency contact called within the first 12 hours of them leaving Beyond Addiction. This will be documented in the EHR. EHR is audited weekly by CCO to ensure compliance. |
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 the review of client records, the project failed to offer a copy of release of information forms in two of seven client records reviewed.
Client #1 was admitted on February 19, 2025 and a current client at the time of the inspection. There was no documentation that the client was offered a copy of the release of information form for a funding source, signed and dated by the client on February 19, 2024.
Client #2 was admitted on February 26, 2025 and a current client at the time of the inspection. There was no documentation that the client was offered a copy of the release of information form for a spouse, signed and dated by the client on February 26, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Intake Coordinators are tasked with ensuring all releases are signed and they are offered copies of all releases. Chief Clinical Officer will perform weekly EHR chart audits to ensure all releases are signed and all clients are offered copies of signed documents. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on the review of client records, the project failed to ensure that methods for control and accountability of drugs, included documenting the staff person administering medications as well as the time and date in four of seven client records.
Client #3 was admitted on February 10, 2025 and was an active client at the time of the inspection. This client is prescribed Topiramate, one tab two times a day; however, on March 6, 2025, only one dose was documented in the record. This client is also prescribed Vraylar, one capsule one time a day; however, there is no documentation that the client received this medication from March 2, 2025 through March 10, 2025. This client is also prescribed Clonidine, one tab one time a day however, there is no documentation that the client received this medication from March 2, 2025 through March 10, 2025.
Client #4 was admitted on January 9, 2025 and was discharged on February 11, 2025. This client was prescribed Ziprosidone, one tab two times a day; however, it was documented that the client only received one tab one time a day from February 1, 2025 through February 10, 2025.
Client #5 was admitted on February 5, 2025 and was discharged on February 28, 2025. This client was prescribed Eliquis, one tab two times a day; however, there was no documentation that the client received this medication February 16, 2025 through February 18, 2025, February 20, 2025 through February 25, 2025 and it is documented that the client only received one dose on February 19, 2025 and February 26, 2025. This client was also prescribed Quetiapine, one tab at 12:00 PM; however, there was no documentation that the client received this medication on February 27, 2025.
Client #6 was admitted on January 6, 2025 and was discharged on February 10, 2025. The client was prescribed Metformin daily; however, there was no documentation that the client received this medication on January 19, 2025 and January 20, 205. The client was also prescribed Vraylar and Lisinopril, one capsule daily; however, there was no documentation that the client received these medications on January 13, 2025 and January 14, 2025. The client was also prescribed Eliquis daily; however, there was no documentation that the client received this medication on January 14, 2025 and January 20, 2025. The client was also prescribed Atorvastatin daily; however, there is no documentation that the client received this medication on January 13, 2025, January 14, 2205, January 18, 2025, January 22, 2025, February 6, 2025 and February 7, 2025. The client was also prescribed Insulin three times a day; however, it was documented that the client only received this medication one time a day on February 2, 2025, February 6, 2025, February 10, 2025 and February 14, 2025 and only twice a day on February 1, 2025 and February 5, 2025. The client was also prescribed Trazadone, Fliquis, and Metoprolol, all to be taken daily; however, there was no documentation that the client received these medications on February 6, 2025 and February 7, 2025. The client was also prescribed Gabapentin three times a day; however, it was documented that this client only received this medication two times a day on February 2, 2025 and February 3, 2025.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
1. Medication Administration Training
Training Objective:
To ensure all staff involved in medication handling, administration, and documentation are competent, compliant with policy, and prepared to manage medication safely and accurately.
Training Content Will Include:
- DDAP standards for medication administration
- Medication storage and safety
- Timely and accurate documentation of administered, missed, or refused medications
- Protocols for handling medication errors or omissions
- Emergency procedures for life-sustaining medications
- HIPAA-compliant communication regarding medications
Training Timeline:
- All current staff will be trained within 30 days of plan implementation.
- New staff will complete training within 14 days of hire.
Frequency:
- Annual refresher training required for all medication staff
- Immediate re-training upon any error or non-compliance incident
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2. Policy Changes
Policy Adjustments Will Include:
- Clear delineation of roles and responsibilities in medication management
- Updated documentation protocols, including a standardized error reporting form
- Emergency protocol for missed doses of life-sustaining medication
- Chain of accountability for reviewing documentation and incident reports
- Refill tracking system policy with medication audit requirements
Impact:
The revised policy will be integrated into the employee handbook and reviewed with all staff during training.
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3. Responsible Parties
- Chief of Staff Development will:
o Coordinate all training efforts
o Maintain training logs and certifications
o Review training content annually to ensure compliance with DDAP changes
- Medication Administration Oversight Officer/Medical Director (MAOO) will:
o Oversee the administration of all medications, especially life-sustaining ones
o Be responsible for monitoring medication documentation daily
o Review and sign off on weekly medication logs
o Respond to and investigate all medication-related incidents
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4. Implementation Monitoring
- Daily medication logs will be checked by assigned nursing/clinical staff and verified weekly by the MAOO.
- A Medication Administration Audit Form will be used monthly to ensure accuracy, completeness, and timeliness of documentation.
- Incident reports related to medication errors/misses will be logged, reviewed within 24 hours, and tracked for trends.
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5. Medication Refill Process
Refill Process:
- Medication refill requests will be submitted by clinical staff 7 days before depletion.
- Medication Coordinator (designated staff) will maintain a Medication Refill Tracker and follow up with pharmacies.
- Clients will be educated to alert staff 10 days before running out of medication as a safety net.
Life-Sustaining Medication:
- Flagged in all client charts and electronic systems
- Requires 48-hour refill turnaround
- Any missed or delayed refill must be reported to the MAOO and Clinical Supervisor immediately
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6. Oversight and Accountability
- MAOO is the primary point of accountability for medication accuracy, training implementation, and emergency protocol execution.
- Chief of Staff Development will conduct quarterly internal audits and file reports with the Executive Director.
- Documentation audits and staff interviews will be included in annual compliance reviews.
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Supporting Materials
- Updated Medication Administration Policy
- Training Curriculum and Sign-In Sheets
- Medication Error/Incident Form
- Medication Refill Tracker Template
- Staff Roles and Oversight Flowchart
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one applicable client record reviewed.
Client #4 was admitted on January 9, 2025 and was involuntarily discharged on February 11, 2025. There was no documentation in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Chief Clinical Officer will ensure that counselors provided written notification to any client who is terminated from the program within 24 hours so explain the termination and allow for 30 days to appeal the termination. The letter will also be uploaded into the EHR chart system for compliance. Chief Clinical Officer will ensure letters are sent and in the client's chart during weekly chart audits. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of the seven records reviewed.
Client #1 was admitted on February 19, 2025 and a current client at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 27, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #5 was admitted on February 5, 2025 and was discharged on February 28, 2025. The individual treatment and rehabilitation plan was completed on February 18, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #6 was admitted on January 6, 2025 and was discharged on February 10, 2025. The individual treatment and rehabilitation plan was completed on January 21, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #7 was admitted on September 19, 2024 and was discharged on October 14, 2024. The individual treatment and rehabilitation plan was completed on September 23, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Beyond Addiction will hire a Clinical Supervisor by 5/21/2025 to ensure proper documentation based on DDAP regulations. Chief Clinical Officer will oversee the Clinical Supervisor will ensure that regulation on documentation are followed during weekly chart audits and have corrective actions for clinical staff who are not compliant. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on the review of client records and the facility ' s policies and procedures, the facility failed to review and update treatment and rehabilitation plans at least every 15 days in three of six applicable client record reviewed.
Client #1 was admitted on February 19, 2025 and a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan was documented in the record on February 27, 2025, and the update was due no later than March 14, 2025; however, the treatment plan update was not documented in the record until March 29, 2025.
Client #3 was admitted on February 10, 2025 and was an active client at the time of the inspection. A comprehensive treatment and rehabilitation plan was documented in the record on March 11, 2025, and the update was due no later than March 26, 2025; however, there was no updated treatment and rehabilitation plan documented in the record at the time of the inspection.
Client #6 was admitted on January 6, 2025 and was discharged on February 10, 2025. A comprehensive treatment and rehabilitation plan was documented in the record on January 21, 2025, and the update was due no later than February 5, 2025; however, the treatment plan update was not documented in the record until February 10, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Plan of Correction:
1. Policy and Procedure Updates
- Documentation of Treatment Plans Timeline: All clinical notes must be entered into the Electronic Health Record (EHR) system within 24 hours of the patient encounter.
- Late Documentation: Any documentation including treatment plans not completed within the specified timeframe will require a justification, subject to supervisory review.
- Audit and Compliance: Supervisors will conduct weekly audits to ensure adherence to documentation timelines including Plan of Correction:
1. Policy and Procedure Updates
- Documentation Timeline: All clinical notes must be entered into the Electronic Health Record (EHR) system within 24 hours of the patient encounter.
- Late Documentation: Any documentation including treatment plans not completed within the specified timeframe will require a justification, subject to supervisory review.
- Audit and Compliance: Supervisors will conduct weekly audits to ensure adherence to documentation timelines, with findings discussed in monthly staff meetings.
2. Staff Training and Education
- Mandatory Training: All clinical staff will undergo a training session on the importance of timely treatment plans documentation, focusing on:
o Compliance with DDAP regulations.
o Impact of timely documentation on patient care and treatment outcomes.
o Efficient use of the EHR system to streamline documentation processes.
- Training Schedule: Initial training will occur within the first week of implementation, with quarterly refresher courses thereafter.
- Documentation Best Practices: Training will emphasize:
o Utilizing standardized templates (e.g., SOAP format) to ensure comprehensive and consistent documentation of treatment plans.
o Avoiding the use of excessive shorthand to maintain clarity.
o Documenting patient interactions promptly to ensure accuracy and completeness.
3. Integration of Technology
- EHR Optimization: The EHR system will be configured to:
o Send automated reminders to clinicians about pending treatment plans.
o Highlight overdue notes to facilitate timely completion.
4. Monitoring and Accountability
- Documentation Audits: Supervisors will perform random audits of clinical notes to assess:
o Timeliness of documentation of treatment plans.
o Adherence to documentation standards.
o Identification of recurring issues or delays.
- Performance Reviews: Documentation practices will be a component of annual performance evaluations, with consistent delays potentially impacting overall performance assessments.
- Feedback Mechanism: Clinicians will receive constructive feedback on their documentation practices, with additional training provided as needed.
5. Continuous Improvement
- Staff Feedback: Regular surveys will be conducted to gather staff input on the documentation process, identifying barriers to timely documentation and areas for improvement.
- Process Refinement: Based on feedback and audit findings, documentation procedures will be adjusted to address identified challenges and enhance efficiency.
- Ongoing Education: The organization will stay updated on best practices for clinical documentation and integrate new strategies or technologies that can improve timeliness and accuracy.
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Responsible Parties
- Clinical Supervisor: Oversee the implementation of the documentation policy, conduct audits, and provide feedback to staff.
- Chief of Staff Development: Coordinate training sessions, ensure staff compliance with training schedules, and evaluate the effectiveness of training programs.
- IT Department: Support the integration and maintenance of EHR system features that facilitate timely documentation, including automated reminders and mobile access solutions.
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Supporting Documentation
- Updated Documentation of treatment plans Policy
- Training Materials and Attendance Records
- Documentation Audit Reports
- Staff Feedback Surveys and Analysis
- Performance Evaluation Criteria
, with findings discussed in monthly staff meetings.
2. Staff Training and Education
- Mandatory Training: All clinical staff will undergo a training session on the importance of timely treatment plans documentation, focusing on:
o Compliance with DDAP regulations.
o Impact of timely documentation on patient care and treatment outcomes.
o Efficient use of the EHR system to streamline documentation processes.
- Training Schedule: Initial training will occur within the first week of implementation, with quarterly refresher courses thereafter.
- Documentation Best Practices: Training will emphasize:
o Utilizing standardized templates (e.g., SOAP format) to ensure comprehensive and consistent documentation of treatment plans.
o Avoiding the use of excessive shorthand to maintain clarity.
o Documenting patient interactions promptly to ensure accuracy and completeness.
3. Integration of Technology
- EHR Optimization: The EHR system will be configured to:
o Send automated reminders to clinicians about pending treatment plans.
o Highlight overdue notes to facilitate timely completion.
4. Monitoring and Accountability
- Documentation Audits: Supervisors will perform random audits of clinical notes to assess:
o Timeliness of documentation of treatment plans.
o Adherence to documentation standards.
o Identification of recurring issues or delays.
- Performance Reviews: Documentation practices will be a component of annual performance evaluations, with consistent delays potentially impacting overall performance assessments.
- Feedback Mechanism: Clinicians will receive constructive feedback on their documentation practices, with additional training provided as needed.
5. Continuous Improvement
- Staff Feedback: Regular surveys will be conducted to gather staff input on the documentation process, identifying barriers to timely documentation and areas for improvement.
- Process Refinement: Based on feedback and audit findings, documentation procedures will be adjusted to address identified challenges and enhance efficiency.
- Ongoing Education: The organization will stay updated on best practices for clinical documentation and integrate new strategies or technologies that can improve timeliness and accuracy.
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Responsible Parties
- Clinical Supervisor: Oversee the implementation of the documentation policy, conduct audits, and provide feedback to staff.
- Chief of Staff Development: Coordinate training sessions, ensure staff compliance with training schedules, and evaluate the effectiveness of training programs.
- IT Department: Support the integration and maintenance of EHR system features that facilitate timely documentation, including automated reminders and mobile access solutions.
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Supporting Documentation
- Updated Documentation of treatment plans Policy
- Training Materials and Attendance Records
- Documentation Audit Reports
- Staff Feedback Surveys and Analysis
- Performance Evaluation Criteria
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709.53(a)(5) LICENSURE Progress Notes
709.53. 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.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include progress notes entered within twenty-four hours of the date of service, per the facility's policy, in five of seven records reviewed.
Client #1 was admitted on February 19, 2025 and a current client at the time of the inspection. The record contained progress notes for individual counseling sessions occurring on March 3, 2025, March 9, 2025, and March 15, 2025, that were not documented in the record until March 28, 2025.
Client #2 was admitted on February 26, 2025 and a current client at the time of the inspection. The record contained progress notes for individual counseling sessions occurring on February 27, 2025, and March 13, 2025, that were not documented in the record until March 7, 2025 and March 31, 2025.
Client #3 was admitted on February 10, 2025 and was an active client at the time of the inspection. The record contained progress notes for individual counseling sessions occurring on February 14, 2025 and February 26, 2025, that were not documented in the record until March 26, 2025 and March 7, 2025. Additionally, the record contained progress notes for individual counseling sessions occurring on March 4, 2025, March 10, 2025 and March 18, 2025, that were not documented in the record until March 28, 2025 and March 31, 2025
Client #4 was admitted on January 9, 2025 and was involuntarily discharged on February 11, 2025. The record contained a progress note for an individual counseling session occurring on February 11, 2025, that was not documented in the record until February 20, 2025.
Client #6 was admitted on January 6, 2025 and was discharged on February 10, 2025. The record contained progress notes for individual counseling sessions occurring on January 13, 2025 and January 27, 2025, that were not documented in the record until February 9, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
1. Policy and Procedure Updates
- Documentation Timeline: All clinical notes must be entered into the Electronic Health Record (EHR) system within 24 hours of the patient encounter.
- Late Documentation: Any documentation not completed within the specified timeframe will require a justification, subject to supervisory review.
- Audit and Compliance: Supervisors will conduct weekly audits to ensure adherence to documentation timelines, with findings discussed in monthly staff meetings.
2. Staff Training and Education
- Mandatory Training: All clinical staff will undergo a training session on the importance of timely documentation, focusing on:
o Compliance with DDAP regulations.
o Impact of timely documentation on patient care and treatment outcomes.
o Efficient use of the EHR system to streamline documentation processes.
- Training Schedule: Initial training will occur within the first week of implementation, with quarterly refresher courses thereafter.
- Documentation Best Practices: Training will emphasize:
o Utilizing standardized templates (e.g., SOAP format) to ensure comprehensive and consistent documentation.
o Avoiding the use of excessive shorthand to maintain clarity.
o Documenting patient interactions promptly to ensure accuracy and completeness.
3. Integration of Technology
- EHR Optimization: The EHR system will be configured to:
o Send automated reminders to clinicians about pending documentation.
o Highlight overdue notes to facilitate timely completion.
4. Monitoring and Accountability
- Documentation Audits: Supervisors will perform random audits of clinical notes to assess:
o Timeliness of documentation.
o Adherence to documentation standards.
o Identification of recurring issues or delays.
- Performance Reviews: Documentation practices will be a component of annual performance evaluations, with consistent delays potentially impacting overall performance assessments.
- Feedback Mechanism: Clinicians will receive constructive feedback on their documentation practices, with additional training provided as needed.
5. Continuous Improvement
- Staff Feedback: Regular surveys will be conducted to gather staff input on the documentation process, identifying barriers to timely documentation and areas for improvement.
- Process Refinement: Based on feedback and audit findings, documentation procedures will be adjusted to address identified challenges and enhance efficiency.
- Ongoing Education: The organization will stay updated on best practices for clinical documentation and integrate new strategies or technologies that can improve timeliness and accuracy.
________________________________________
Responsible Parties
- Clinical Supervisor: Oversee the implementation of the documentation policy, conduct audits, and provide feedback to staff.
- Chief of Staff Development: Coordinate training sessions, ensure staff compliance with training schedules, and evaluate the effectiveness of training programs.
- IT Department: Support the integration and maintenance of EHR system features that facilitate timely documentation, including automated reminders and mobile access solutions.
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Supporting Documentation
- Updated Documentation Policy
- Training Materials and Attendance Records
- Documentation Audit Reports
- Staff Feedback Surveys and Analysis
- Performance Evaluation Criteria
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