INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on February 10, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated 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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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 keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in five of seven client records reviewed. Client # 1 was admitted on November 26, 2019 and was still active at the time of the inspection. The record contained a consent to release information form to the funding source, signed and dated by the client on November 26, 2019, that allowed for the release of intake/admission information, plan of care/review, psychiatric evaluation, medications prescribed, medical history and physical, lab results and discharge summary/plan, all of which exceeded the limits established by 4 Pa. Code 255.5. Client # 2 was admitted on December 24, 2019 and was still active at the time of the inspection. The record contained a consent to release information form to the funding source, signed and dated by the client on May 20, 2019, that allowed for the release of intake/admission information, plan of care/review and psychiatric evaluation, all of which exceeded the limits established by 4 Pa. Code 255.5. Client # 3 was admitted on July 22, 2019 and was still active at the time of the inspection. The record contained a consent to release information form to the family court, signed and dated by the client on December 16, 2019, that allowed for the release of care/review, psychiatric evaluation, medications prescribed, lab results, psychosocial assessments and discharge summary/plan, all of which exceeded the limits established by 4 Pa. Code 255.5.Client # 6 was admitted on December 31, 2019 and was discharged on July 29, 2020. The record contained a consent to release information form to the funding source, signed and dated by the client on December 31, 2019, that allowed for the release of intake/admission information, psychiatric evaluations, psychological evaluation/report and treatment plan/plan of care, all of which exceeded the limits established by 4 Pa. Code 255.5.Client # 7 was admitted on May 19, 2020 and was discharged on February 5, 2021. The record contained a consent to release information form to the funding source, signed and dated by the client on May 19, 2020 that allowed for the release of intake/admission information, psychiatric evaluations and psychological assessment, all of which exceeded the limits established by 4 Pa. Code 255.5.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
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.
In an effort to meet standard 709.28 (c) (2) Licensure Confidentiality. Effective immediately Clients currently active in treatment who have consents that exceed 4 Pa Code 255.5, will be informed that their consent(s) on file will be revoked immediately. If the revoked consent(s) is a consent in which the Clients wants to maintain program communication with the identified source, the Client will be asked to sign a revised copy of the consent. The revised copy of the consent fully meets the above standards. Clients will be informed of the information the program may release with the signed informed and voluntary consent, which will be limited to: (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 abuse and frequency of such relapse in accordance with 4 Pa Code 255.5. Any staff member responsible to complete release of information forms will be retrained to select the proper program (Drug and Alcohol) within the EHR system which is designed to automatically limit the information allowed to be released for licensed Drug and Alcohol Programs governed by 709.28 Licensure Confidentiality and 4 Pa Code 255.5.
The Front Desk Supervisor will ensure all front desk staff are retrained by March 15, 2021, and the clinical staff will be formally retrained on March 19, 2021 to relearn how to properly select the Substance use program, under the consent in the Electronic Health Records, to force limitations for 4 Pa Code 255.5.
The Clinical Supervisor for drug & alcohol services will review all active client records to ensure client records meet 709.28 (c)(2) Confidentiality prior to March 15, 2021.
Monitoring: The Site Director will be responsible to review new client records to ensure release of information forms are within limits established by 4 Pa Code 255.
On-going monitoring will be conducted monthly by the QA Department and daily by the Front Desk Manager to ensure program compliance.
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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 client records, the facility failed to document the dated signature of the client on release of information forms in one of seven client records reviewed. Client # 5 was admitted on September 22, 2020 and was discharged on December 29, 2020. The release of information form to the parole officer was signed and dated by the witness on October 22, 2020 but it was not signed by the client. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address the deficiency associated with standard 709.28 (c)(4) Confidentiality, Registration Assistants, Urgent Care Specialists, and Counselor IIIs, will review the active client records to ensure compliance with the presence of a dated signature of client.
Site Director scheduled a meeting with the clinical team on March 5, 2021. A copy of Regulation 709.28 (c)(4) was distributed and read to Registration Assistants, Urgent Care Specialists, and Counselor IIIs. An explanation was provided detailing the importance of obtaining a client signature on consent documentation based on standard 709.28 (c)(4). Registration Assistants, Urgent Care Specialists, and Counselor IIIs, was asked to sign the copy of the regulation, attesting that they have reviewed and understand the regulation. A copy of the signed regulation was given to the staff and the site director maintained a copy.
Deficiencies will be resolved by April 15, 2021. This will allow time for clients to be notified, and make arrangements to present to the site to sign consents. Effective March 5, 2021, Registration Assistants, Urgent Care Specialists, and Counselor IIIs will ensure that the dated signature of the client has been captured prior to capturing the dated signature of the witness.
Client Service Coordinator and/or Clinical Coordinator/Supervisor will conduct periodic audits and review process for obtaining consents in biweekly supervision meetings, in order to remain in compliance with standard 709.28 (c)(4) Confidentiality.
Monitoring will be Ongoing by Clinical Coordinator/Supervisor and Quality Assurance (QA) Department. Audit findings will be reported to Leadership Team, Quality Assurance Department, and Chief Behavioral Health Officer during bi-weekly Leadership meetings.
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review client records, the facility failed to document the dated signature of the witness on release of information forms in one of seven client records reviewed. Client # 2 was admitted on December 24, 2019 and was still active at the time of the inspection. The release of information forms to the laboratory, the emergency contact and the funding source were signed and dated by the client on May 20, 2019 but there was no dated witness signature. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address the deficiency associated with standard 709.28 (c)(5) Confidentiality, Registration Assistants, Urgent Care Specialists, and Counselor IIIs, will review the active client records to ensure compliance with the presence of a dated signature of witness. The Clinician will request that the client present to site to resign consents to be witnessed by the Clinician or Registration Assistant obtaining consent as determined necessary.
Site Director scheduled a meeting with the clinical team on March 5, 2021. A copy of Regulation 709.28 (c)(5) was distributed and read to Registration Assistants, Urgent Care Specialists, and Counselor IIIs. An explanation was provided detailing the importance of providing a dated witness signature on consent documentation based on standard 709.28 (c)(5). Registration Assistants, Urgent Care Specialists, and Counselor IIIs, was asked to sign the regulation, attesting that they have reviewed and understand the regulation. A copy of the signed regulation was given to the staff and the site director maintained a copy.
Deficiencies will be resolved by April 15, 2021. This will allow time for requests to be made for clients to make arrangements to present to the site to resign consents. Effective March 5, 2021, Registration Assistants, Urgent Care Specialists, and Counselor IIIs will ensure that the dated signature of witness has been captured immediately following receipt of the client's dated signature.
Client Service Coordinator and/or Clinical Coordinator/Supervisor will conduct periodic audits and review process for obtaining consents in biweekly supervision meetings, in order to remain in compliance with standard 709.28 (c)(5) Confidentiality.
Monitoring will be Ongoing by Clinical Coordinator/Supervisor and Quality Assurance (QA) Department. Audit findings will be reported to Leadership Team, Quality Assurance Department, and Chief Behavioral Health Officer during bi-weekly Leadership meetings.
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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 document that a copy of a client consent was offered to the client in each release of information form in seven out of seven client records reviewed. Client # 1 was admitted on November 26, 2019 and was still active at the time of the inspection. The release of information forms were signed by the client and witness on November 26, 2019 but they did not document that a copy of the consent was offered to the client. Client # 2 was admitted on December 24, 2019 and was still active at the time of the inspection. The release of information forms were signed by the client and witness on February 9, 2019 and by the client on May 20, 2019 but they did not document that a copy of the consent was offered to the client. Client # 3 was admitted on July 22, 2019 and was still active at the time of the inspection. The release of information forms were signed by the client and witness on January 19, 2021 and December 16, 2019 but they did not document that a copy of the consent was offered to the client. Client # 4 was admitted on October 21, 2019 and was discharged on June 12, 2020. The release of information forms were signed by the client and witness on October 21, 2019 but they did not document that a copy of the consent was offered to the client. Client # 5 was admitted on September 22, 2020 and was discharged on December 29, 2020. The release of information forms were signed by the witness on October 22, 2020 and by the client and witness on September 22, 2020 but they did not document that a copy of the consent was offered to the client. Client # 6 was admitted on December 31, 2019 and was discharged on July 29, 2020. The release of information forms were signed by the client and witness on December 31, 2019 but they did not document that a copy of the consent was offered to the client. Client # 7 was admitted on May 19, 2020 and was discharged on February 5, 2021. The release of information forms were signed by the client and witness on May 19, 2020 but they did not document that a copy of the consent was offered to the client. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To comply with regulation 709.28 (d) Confidentiality, documentation will be visible in the client record to show that the Provider offered a copy of the client consent to the client in each release of information, and that the client accepted or refused a copy of the consent. A copy of the consents will be maintained in the client record.
The findings concluded that the section of the Electronic Health Record where it should be indicated that the client accepted or refused a copy of the consent was missing, and the EHR system did not show a copy offered when printed or displayed on screen. This section of the form did show on screen when a new form was added. The issue has been reported to the Chief Behavioral Health Officer. A ticket was placed with our EHR vendor to notify them of the problem.
The EHR vendor has resolved the glitch this information is not viewable and printable.
Upon completion of a release of information, Registration Assistant, Urgent Care Specialist, or Counselor III will continue to offer the client a copy and check the box to indicate a copy was offered or refused. Effective 3/5/21, Registration Assistant, Urgent Care Specialist, or Counselor III will document in a note that they offered the client a copy of the Consent/Release of Authorization and indicate that the client accepted or refused a copy as a backup until we are certain that the glitch has truly been resolved.
Monitoring: The Site Director along with the Clinical Coordinator/Supervisor will provide ongoing monitoring of client records to ensure compliance with regulation 709.28 (d). The IS department has been asked to monitor the EHR system periodically for such glitches. Audit findings will be reported to Leadership Team, Quality Assurance Department, and Chief Behavioral Health Officer during bi-weekly Leadership meetings.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in three of three applicable patient records reviewed. Patient # 1 was admitted on November 26, 2019 and was still active at the time of the inspection. The record of service and progress notes showed that less 2.5 hours of psychotherapy per month were provided during the following months:- January 2021 - 1 hour documented- December 2020 - 1 hour documented- November 2020 - 30 minutes documentedPatient # 2 was admitted on December 24, 2019 and was still active at the time of the inspection. The record of service and progress notes showed that less 2.5 hours of psychotherapy per month were provided during the following months:- January 2021 - 1 hour documented- December 2020 - 1 hour documented- November 2020 - 1 hours and 30 minutes documentedPatient # 3 was admitted on July 22, 2019 and was still active at the time of the inspection. The record of service and progress notes showed that less 2.5 hours of psychotherapy per month were provided during the following months:- January 2021 - 1 hour documented- December 2020 - 1 hour documented- November 2020 - 1 hour documentedThese findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address the deficiency associated with standard 715.19 (1) Psychotherapy Services, clients will be scheduled for, and receive, a combination of 2.5 hours of individual and group therapy, with a minimum of 1 hour for individual therapy per month.
Clients will be scheduled more frequently during the course of the month to accommodate the no-show rate while allowing for the standard to be met. Site Director and Clinical Coordinator will re-establish full group treatment options within the next 30 days, which was impacted by COVID-19. This will allow time for the coordination of a more flexible group scheduled (days, times and duration) and for members to be scheduled in advance and to troubleshoot any technical issues prior to the scheduled group.
Clinician will schedule existing clients for at least two hours of individual therapy per month and identify appropriate group treatment options to be discussed with, and assigned to, client in order to comply with standard 715.19 (1).
Clinician will monitor client's individual therapy and group attendance weekly to ensure compliance with standard 715.19 (1).
Monitoring: The Site Director along with the Clinical Coordinator, will provide ongoing monitoring of client records to ensure compliance with regulation 715.19 (1). Audit findings will be reported to Leadership Team, Quality Assurance Department, and Chief Behavioral Health Officer during bi-weekly Leadership meetings
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in four of seven client records reviewed. Client # 1 was admitted on November 26, 2019 and was still active at the time of the inspection. The client record did not document a psychosocial evaluation. Client # 2 was admitted on December 24, 2019 and was still active at the time of the inspection. The client record did not document a psychosocial evaluation. Client # 5 was admitted on September 22, 2020 and was discharged on December 29, 2020. The client record did not document a psychosocial evaluation. Client # 6 was admitted on December 31, 2019 and was discharged on July 29, 2020. The client record did not document a psychosocial evaluation. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address the deficiency associated with standard 709.91 (b)(6) Intake and Admission, the facility will comply with completion of psychosocial evaluations in accordance with the standard. A refresher training will be conducted on March 19, 2020, This training will cover the programs requirement of turning the CBE into a psychosocial evaluation narrative (Clinical Impression) that meets the standard of 709.91 (b) (6) immediately following the completion the evaluation. Urgent Care Specialists, Counselor IIIs, and Supervisors will audit all active client records in order to identify client records that need to be brought into compliance according to standard 709.91 (b)(6). Deficiencies will be resolved by April 15, 2021.
Ongoing, the Clinician will ensure that the psychosocial evaluation has been completed by the end of the client's date of service. Clinical Coordinator/Supervisor will conduct periodic audits and review standards in biweekly supervision meetings, in order to establish and remain in compliance with standard 709.91 (b)(6) Intake and Admission.
Site Director will be responsible to provide on-going monitoring of the Clinical Supervisors to ensure review of client records to meet policy and compliance with standard 709.91 (b)(6).
Monitoring:
The Site Director will be responsible to provide on-going feedback regarding treatment and rehabilitation management during monthly leadership team meetings with Counselor III, Quality Assurance Department, and the Chief Behavioral Health Officer.
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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, the facility failed to review and update each client's treatment plan at least every 60 days in six of seven client records reviewed.Client # 1 was admitted on November 26, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was completed on December 3, 2019 and the next update was due no later than February 3, 2020; however, the update was not completed until June 25, 2020. Client # 2 was admitted on December 24, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was completed on December 11, 2019 and the next update was due no later than February 11, 2020; however, the update was not completed until April 28, 2020. Additionally, a treatment plan update was completed on June 25, 2020 and the next update was due no later than August 25, 2020; however, the update was not completed until October 22, 2020. Client # 4 was admitted on October 21, 2019 and was discharged on June 12, 2020. A treatment plan update was completed on February 3, 2020, and the next update was due no later than April 3, 2020; however, the update was not completed prior to discharge.Client # 5 was admitted on September 22, 2020 and was discharged on December 29, 2020. The comprehensive treatment plan was completed on October 22, 2020 and the next update was due no later than December 22, 2020; however, the update was not completed prior to discharge. Client # 6 was admitted on December 31, 2019 and was discharged on July 29, 2020. A treatment plan update was completed on February 13, 2020, and the next update was due no later than April 13, 2020; however, the update was not completed prior to discharge.Client # 7 was admitted on May 19, 2020 and was discharged on February 5, 2021. The comprehensive treatment plan was completed on June 2, 2020, and the next update was due no later than August 2, 2020; however, the update was not completed prior to discharge.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address the deficiency associated with standard 709.92 (b) the facility will comply with treatment and rehabilitation management, according to the policy the facility has put in place to complete treatment plans every 60 days. The following measures will be put in place, so that treatment and rehabilitation management standards are met: The Clinical Supervisor in conjunction with the Quality Assurance team will utilize a tracking system for all active cases. The tracker will not display any patient identifying information except for the client record number. The tracker will be reviewed by the Clinical Supervisor, the Counselor III and the Drug & Alcohol Committee on a weekly basis for the first 90 days and monthly thereafter. Deficiencies will be resolved by April 15, 2021.
Ongoing, the Clinician will meet with client on the sixtieth day or sooner to complete the treatment plan. Clinician will check daily audits of treatment plans provided by the Quality Assurance Department, and update all treatment plans that will be in compliance within the next week. Clinicians will email completion of these updated treatment plans to their supervisors weekly as the Clinical Supervisors will be monitoring the quality assurance report beginning March 8, 2021. Clinical Supervisors will also complete daily audits of at least five charts from each clinician and review charts for compliance during biweekly supervision.
Site Director will be responsible to provide on-going monitoring of the Clinical Supervisors to ensure review of client records to meet facility policy and compliance with standard 709.92 (b). An in-service meeting will be held on March 19, 2021 with the Clinical staff, to review timelines regarding the development, approval, monitoring, and evaluation of client services, which will include but not be limited to treatment planning, case consultation, level changes, and discharge.
Monitoring: The Site Director will be responsible to provide on-going feedback regarding treatment and rehabilitation management during monthly leadership team meetings with Counselor III, Quality Assurance Department, and the Chief Behavioral Health Officer.
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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 document case consultation notes in four of six applicable client records reviewed. Client # 1 was admitted on November 26, 2019 and was still active at the time of the inspection. The client record did not document case consultation notes. Client # 2 was admitted on December 24, 2019 and was still active at the time of the inspection. The client record did not document case consultation notes. Client # 4 was admitted on October 21, 2019 and was discharged on June 12, 2020. The client record did not document case consultation notes. Client # 6 was admitted on December 31, 2019 and was discharged on July 29, 2020. The client record did not document case consultation notes. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address the deficiency associated with standard 709.93 (a)(8) the facility will comply with the completion of case consultation notes every 90 days for the first year and annually thereafter. The following measures will be put in place, so that case consultation standards are met: The Clinical Supervisor in conjunction with the Quality Assurance team will utilize a tracking system for all active cases. The tracker will not display any patient identifying information except for the client record number. The tracker will be reviewed by the Clinical Supervisor, the Counselor III and the Drug & Alcohol Committee on a weekly basis for the first 90 days and monthly thereafter.
The Clinician will bring current active charts into compliance with standard 709.93 (a)(8) within the next 30 days, and complete case consultation notes every 90 days for the first year to be presented in clinical meetings two times a month. Clinician will check daily audits of treatment plans provided by the Quality Assurance Department, and complete case consultations in compliance with standard 709.93 (a)(8). Clinical Supervisors will monitor the quality assurance report beginning March 8, 2021. Clinical Supervisors will also complete daily audits of at least five charts from each clinician and review charts for compliance during biweekly supervision.
Site director will be responsible to provide on-going monitoring of the Clinical Supervisors to ensure review of client records to meet facility policy and compliance with standard 709.93 (a)(8). An in-service meeting will be held on March 19, 2021 with the Clinical staff, to review timelines regarding the development, approval, monitoring, and evaluation of client services, which will include but not be limited to treatment planning, case consultation, level changes, and discharge.
Monitoring: The Site Director will be responsible to provide on-going feedback regarding treatment and rehabilitation management during monthly leadership team meetings with Counselor III, Quality Assurance Department, and the Chief Behavioral Health Officer.
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