INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 25, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, 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 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on the physical plant inspection conducted on September 25, 2017 at approximately 1:00 pm, it was discovered that the facility failed to secured patient records in locked storage containers. The first floor file room door was unlocked and unattended.The findings were reviewed with facility staff during the licensing process
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Plan of Correction
Plan of Correction:
709.28 (b) LICENSURE Confidentiality:
In an effort to maintain compliance for 709.28. (b) Confidentiality. The Chief Behavioral Healthcare Officer met with the Quality Assurance Manager and Director of Maintenance. As a result the following Corrective Action Plan has been put in place:
The Quality Assurance Manager held a meeting with the Quality Control Clerks on September 29, 2017 to reiterate the important of protecting Clients' records at all times and keeping the file room locked.
In addition, 709.28 LICENSURE Confidentiality: will be reviewed with the Quality Control Clerks on October 27, 2017, during the QA staff meeting.
As an additional measure to ensure compliance with Standard 709.2 (b), automatic door locks will be placed on the Records Room Doors to avoid human error.
Corrective Action Completion Date: October 27, 2017.
Monitoring On-going:
Compliance for 709.2 (b) will be monitored randomly by the Quality Assurance Manager and QA Coordinators and daily by the Security Guards during their walkthrough rounds. |
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 7 client records, 5 records had treatment plan updates completed after the regulatory timeframe or missing at the time of the inspection.Client #1 was admitted on 1/5/16 and was an active patient at time of inspection. A treatment plan update was completed 1/5/17 and the next update was due no later than 3/5/17. However, the next update was not completed at the time of inspection.Client #2 was admitted on 1/27/16 and was an active patient at time of inspection. A treatment plan update was completed 11/10/16 and the next update was due no later than 1/10/17. However, the next update was not completed until 1/25/17. Client #3 was admitted on 8/17/16 and was an active patient at time of inspection. A treatment plan update was completed 5/30/17 and the next update was due no later than 7/30/17. However, the next update was not completed until 8/22/17.Client #4 was admitted on 11/5/16 and was discharged on 10/3/16. A treatment plan update was completed 7/1/16 and the next update was due no later than 9/1/16. However, the next update was not completed at the time of inspection. Client #6 was admitted on 1/20/16 and was discharged on 8/18/17. A treatment plan update was completed 6/5/17 and the next update was due no later than 8/5/17. However, the next update was not completed at the time of inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Plan of Correction:
709.92(b) LICENSURE - TREATMENT AND REHABILITATION SERVICES
CORRECTIVE ACTION:
In an effort to establish and maintain full compliance with regulation 709.92 (b), the findings from the September 26, 2017, were reviewed by the Chief Behavioral Healthcare Officer, Clinical Leadership Team and CEO/Executive Director. As a result of the findings and full review of the cases found in non-compliance, strategic planning meetings were held with the Clinical Leadership Team on Monday, October 2, 9, and 16th, to review Standards including but not limited to Standard 709.92(b) LICENSURE TREATMENT and REHABILITATION: and to explore why inconsistency in meeting this particular standard continue to occur.
As a result of these meetings, the following plan of correction has been put in place:
An in-service training has been scheduled for November 17, 2017, entitled Maintaining Compliance Connections Even Throughout Direct-Service Disconnects. The training will focus on How to Streamline and Manage a Caseload using Required Time-Lines as a Friendly Tool for initiating and Updated Treatment Plans: How to Handle Compliant and Non-Compliant Clients when Treatment Plans are Due and up for Review. How to Use the Clinical Leadership Team as the Compliance Enforcers.
Along with a refresher on:
- Developing Initial Treatment Plans
- Developing Comprehensive Treatment Plans
- Developing Treatment Plan Up-Dates
- Documenting the type and frequency of treatment and rehabilitative services
- Proposed Support Services
-Review of required content
Monitoring:
Therapist will review their Caseload management list daily and discuss Treatment Plan Status at Check-in each morning for Clients scheduled that day and scheduling/engagement plans for Clients that Treatment Plans are due in the upcoming week.
Clinical Supervisors will review at minimum eight charts per week for Treatment Plan Compliance and report findings immediately to Therapist if corrections are needed.
Clinical Supervisors will submit a weekly report in the form of a PPD to the CBHO for compliance trend monitoring.
The Quality Control Clerks will conduct daily audits to ensure Treatment Plan time-lines are in compliance and notify Therapist and Supervisor in writing of any infractions.
The Drug and Alcohol Coordinator, Clinical Supervisors and Quality Assurance Coordinators will conduct weekly random reviews to ensure that all aspects of treatment plans are in compliance with standard 709.92.
TIME FRAME FOR COMPLETION:
November 17, 2017- Ongoing Monitoring
Evaluation of Monitoring Process
Weekly by the Quality Assurance Manager and Drug and Alcohol Coordinator
Every 30-days by the CBHO and QAM reviewing trend reports
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