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 9, 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 Dental and Behavioral Health 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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709.24 (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 own written procedures for the management of treatment/rehabilitation services for clients in six of seven records reviewed.The facility policy and procedure manual stated that the comprehensive treatment plan is to be completed within 15 working days from admission.Client # 4 was admitted on August 30, 2019 and was discharged on June 22, 2020. The comprehensive treatment plan was due to be completed no later than September 20, 2019; however, the treatment plan was not completed until October 29, 2019. Client # 7 was admitted on August 14, 2019 and was discharged on November 5, 2020. The comprehensive treatment plan was due to be completed no later than September 4, 2019; however, the treatment plan was not completed until December 16, 2019. The facility policy and procedure manual stated that case consultation notes are to be documented every 90 days. Client # 1 was admitted on August 7, 2019 and was still active at the time of the inspection. Case consultation notes were documented on May 14, 2020 and February 9, 2021; not every 90 days. Client # 2 was admitted on February 27, 2020 and was still active at the time of the inspection. Case consultation notes were documented on February 9, 2021, not every 90 days.Client # 3 was admitted on June 22, 2020 and was still active at the time of the inspection. Case consultation notes were documented on January 19, 2021 and February 5, 2021, not every 90 days. Client # 4 was admitted on August 30, 2019 and was discharged on June 22, 2020. Case consultation notes were documented on January 19, 2021 and January 25, 2021, not every 90 days. Client # 6 was admitted on November 18, 2019 and was discharged on August 9, 2020. Case consultation notes were documented on May 15, 2020; not every 90 days. Client # 7 was admitted on August 14, 2019 and was discharged on November 5, 2020. Case consultation notes were documented on May 14, 2020; not every 90 days. The facility policy and procedure manual states that the biopsychosocial history and evaluation is to be completed within 30 working days from admission. Client # 4 was admitted on August 30, 2019 and was discharged on June 22, 2020. The biopsychosocial history and evaluation were due to be completed by October 15, 2020; however, the history and evaluation were not completed until October 29, 2020. Client # 7 was admitted on August 14, 2019 and was discharged on November 5, 2020. The biopsychosocial history and evaluation were due to be completed by September 25, 2020; however, the history was not completed until November 13, 2019 and evaluation was not completed until May 14, 2020. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CORRECTIVE ACTION:
In an effort to maintain compliance with Standard 709.24 (a) (3) and the policy of GPHA/Al-Assist Behavioral Healthcare Center, the Chief Behavioral Healthcare Officer has reviewed and revised the agencies policy on Treatment Planning to coincide with Standard 709.24 (a) (3), removing the need to develop what was referred to by the agency as a Comprehensive Treatment Plan to be developed within 15-working days after the initial/preliminary plan. The revised policy follows the language of Standard 709.24 (a) (3). The revised policy was presented during the in-service on March 19, 2021, with a focus on content, completion timeframe, and correlation with the progress notes. The new policy goes into effect on Monday, March 19, 2021.
In an effort to meet the standards of 709.24 (a) (3) the facility has put the following measures in place. The Clinical Supervisor in conjunction with the Quality Assurance team developed 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 IIIs and the Drug & Alcohol Committee on a weekly basis for the first 90 days and monthly thereafter for compliance.
On-going Monitoring: The Site Director will be responsible to provide on-going feedback regarding treatment and rehabilitation management during morning check-in, monthly staff meetings and supervisions.
QA Department will monitor compliance prior and within 24-hours after all scheduled visits. Reports of all findings will be provided to Counselor IIIs, Clinical Coordinators and Clinical Supervisors in an effort to ensure compliance at time of visit.
The DA Committee will review all reports to measure compliance and further develop strategies to ensure compliance at no less than 100% accuracy
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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 one of seven client records reviewed. Client # 7 was admitted on August 14, 2019 and was discharged on November 5, 2020. The record contained a consent to release information form to the funding source, signed and dated by the client on August 14, 2019, that allowed for the release of intake/admission information and the plan of care/review, both of which exceed the limits established by 4 Pa. Code 255.5.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to meet standard 709.28 (c) (2) Licensure Confidentiality Client currently active in treatment who has a consent that exceed 4 Pa Code 255.5, will be informed that their consent on file has been revoked. Upon next scheduled visit, therapist will update this consent with the Client. The updated consent will be limited to 4 Pa Code 255.5. information to release on the consent shall only include the following: (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 addition, all staff members responsible to complete consents to release information will be retrained on the consents/authorizations section within the Electronic Health Record.
Retraining and testing on consents/authorizations policy and workflows based on Drug and Alcohol programs has commenced and shall be completed on March 19, 2021.
The Clinical Supervisor for drug & alcohol services will review all client records to ensure client records meet 709.28 (c)(2) Confidentiality.
Monitoring: The Clinical Coordinator and Site Director will be responsible to monitor client records to ensure staff are following the proper workflow that would prohibit the release of information that would exceed the limits established by 4 Pa Code 255.5.
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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 # 3 was admitted on June 22, 2020 and was still active at the time of the inspection. The release of information form to a medical provider was signed and dated by the witness on January 8, 2021, but the form was not signed by the client. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
CORRECTIVE ACTION:
In an effort to address the deficiency associated with standard 709.28 (c)(4) Confidentiality: Site Director held a meeting on March 5, 2021, with the site. A copy of Regulation 709.28 (c)(4) was distributed and read. Further explanation was provided detailing the importance of obtaining a client signature on consent documentation based on standard 709.28 (c)(4). Staff were asked to sign the document, attesting that they have reviewed and understand the regulation.
Any consent to release information obtained during the pandemic that indicated the Client provided verbal consent during a telehealth visit will be revoked immediately.
Signatures for new consents will be obtained electronically through the technology of DocuSign for Clients unwilling to come on-site due to the pandemic and related/compromised medical conditions. Clients who do not have the technology or skills to use DocuSign will not be required to sign any consents involving release/disclosure until the Clients is comfortable coming on-site for services. Clients who agree to receiving their consents via U.S. Mail will be required to sign, date and place the consents in the return stamped envelope during the virtual telehealth visit, so that the consents can be witnessed by the therapist. All required signatures and dates will be captured on-site using the standard signature pad for Clients during face-to-face for those who are willing to receive and provide services on site using PPE and practicing social distancing. Effective March 5, 2021, no consent will be captured unless all signature capturing technology is fully operating that allows all parties the ability to sign and date the consent. Consents received back via U.S. Mail will be signed by the witnessing therapist and scanned into the Client's electronic health record.
The Discharge and Admissions Department will review new admits within 24-hours to ensure compliance of standard 709.28 (c) (4). Clinical Coordinator/Supervisor will conduct periodic audits reviewing consents in preparation for biweekly supervision meetings.
Monitoring will be Ongoing by Site Director and Quality Assurance (QA) Department to measure progress and compliance. Audit findings will be reported to Leadership Team 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 for each release of information form reviewed in seven of seven client records reviewed. Client # 1 was admitted on August 7, 2019 and was still active at the time of the inspection. The release of information forms were signed by the client on October 9, 2019 and August 7, 2019 but they did not document that a copy of the consent was offered to the client. Client # 2 was admitted on February 27, 2020 and was still active at the time of the inspection. The release of information forms were signed by the client on January 7, 2021, July 23, 2020, April 3, 2020 and February 27, 2020 but they did not document that a copy of the consent was offered to the client. Client # 3 was admitted on June 22, 2020 and was still active at the time of the inspection. The release of information forms were signed by the client on January 8, 2021 and June 22, 2020 but they did not document that a copy of the consent was offered to the client. Client # 4 was admitted on August 30, 2019 and was discharged on June 22, 2020. The release of information forms were signed by the client on August 30, 2019 but they did not document that a copy of the consent was offered to the client. Client # 5 was admitted on February 3, 2020 and was discharged on July 7, 2020. The release of information forms were signed by the client on February 3, 2020 but they did not document that a copy of the consent was offered to the client. Client # 6 was admitted on November 18, 2019 and was discharged on August 9, 2020. The release of information forms were signed by the client on November 18, 2019 but they did not document that a copy of the consent was offered to the client. Client # 7 was admitted on August 14, 2019 and was discharged on November 5, 2020. The release of information forms were signed by the client on August 14, 2019 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
CORRECTIVE ACTION:
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. The EHR glitch will be corrected no later than April 15, 2021.
Upon completion of a release of information, Registration Assistant, Urgent Care Specialist, or Counselor III will 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 have offered the client a copy of the Consent/Release of Authorization and indicate that the client accepted or refused a copy.
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). 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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709.92(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 treatment and rehabilitation plans at least every 60 days in seven of seven client records reviewed. Client # 1 was admitted on August 7, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was completed on September 10, 2019 and an update was due no later than November 10, 2019; however, the update was not completed until April 2, 2020. Additionally, a treatment plan update was completed on June 1, 2020 and an update was due no later than August 1, 2020; however, the update was not completed until August 28, 2020. Client # 2 was admitted on February 27, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was completed on March 5, 2020 and an update was due no later than May 5, 2020; however, the update was not completed until June 26, 2020. Additionally, a treatment plan update was completed on October 12, 2020 and an update was due no later than December 12, 2020; however, the update was not completed until February 9, 2021. Client # 3 was admitted on June 22, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was completed on July 21, 2020 and an update was due no later than September 21, 2020; however, the update was not completed until December 2, 2020. Client # 4 was admitted on August 30, 2019 and was discharged on June 22, 2020. The comprehensive treatment plan was completed on October 29, 2019 and the next update was due no later than December 29, 2019; however, the update was not completed until February 3, 2020. Additionally, a treatment plan update was completed on February 3, 2020 and the next update was due no later than April 3, 2020; however, there was no update completed prior to discharge. Client # 5 was admitted on February 3, 2020 and was discharged on July 7, 2020. A treatment plan update was completed on April 25, 2020 and the next update was due no later than June 25, 2020; however, there was no update completed prior to discharge. Client # 6 was admitted on November 18, 2019 and was discharged on August 9, 2020. The comprehensive treatment plan was completed on December 23, 2019 and an update was due no later than February 23, 2020; however, the update was not completed until April 22, 2020. Additionally, a treatment plan update was completed on April 22, 2020 and an update was due no later than June 22, 2020; however, there was no update completed prior to discharge. Client # 7 was admitted on August 14, 2019 and was discharged on November 5, 2020. A treatment plan update was completed on February 27, 2020 and the next update was due no later than April 27, 2020; however, there was no update completed prior to discharge. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CORRECTIVE ACTION:
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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709.92(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 provided according to the individual treatment and rehabilitation plan in four of seven client records reviewed. Client # 1 was admitted on August 7, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated September 10, 2019, indicated the client was to receive bi-weekly individual therapy sessions (two individual sessions per month). The chart's record of service and progress notes indicated that the client had received one individual session during September 2019, one individual session during November 2019 and one individual session during December 2019.Client # 2 was admitted on February 27, 2020 and was still active at the time of the inspection. The comprehensive treatment plan, dated March 5, 2020, indicated the client was to receive one individual therapy session per week (four individual sessions per month). The chart's record of service and progress notes indicated that the client had received two individual sessions during April 2020, no individual sessions during May 2020 and one individual session during June 2020. Client # 4 was admitted on August 30, 2019 and was discharged on June 22, 2020. The comprehensive treatment plan, dated October 29, 2019, indicated the client was to receive bi-weekly individual therapy sessions (two individual sessions per month). The chart's record of service and progress notes indicated that the client had received one individual session during November 2019, no individual sessions during December 2019 and one individual sessions during January 2020. Client # 6 was admitted on November 18, 2019 and was discharged on August 9, 2020. The comprehensive treatment plan, dated December 23, 2019, indicated the client was to receive bi-weekly individual therapy sessions (two individual sessions per month). The chart's record of service and progress notes indicated that the client had received no individual sessions during January 2020 and one individual session during March 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CORRECTIVE ACTION:
In an effort to address the deficiency associated with standard 709.92 (c) Treatment and rehabilitation services, the Project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
The following measures will be put in place, so that treatment and rehabilitation management standards are met: During the scheduled in-service training on March 19, 2021, the Clinical supervisors conducted a training on treatment planning and progress note correlation. The training focused on the importance of using the treatment plan as the instructions/guide for the individual session. Along with, documenting how, when or why services have deviated from the plan within any 60-day or less time period. Whether, it is the frequency of care, care of services provided, or objectives; clinical documentation must be in the Client's record giving an explanation for the change and/or causal factor(s) that has led to a deviation from the last treatment and rehabilitation plan. Therapist were instructed to place such notations in the progress notes, case management notes, and no show notes.
The Clinical Supervisor, Counselor IIIs and Drug & Alcohol Committee will meet on a weekly basis for the first 90 days and monthly thereafter to review treatment and rehabilitation planning and progress notes to ensure correlation and cohesiveness.
Ongoing, the Counselor IIIs during individual sessions will review the active treatment and rehabilitation plan with the Client along with the session plan at the end of each individual session to ensure that both the Counselor III and Client are aware of the treatment agreement and are on-point with the plan of care. This will allow the Client to provide feedback during the session as to why agreed upon task/plans were not completed and/or will not be adhered to in the upcoming week.
Clinical Supervisors will be reviewing at least five charts daily from each counselor III, focusing on standard 709.92 (c). Findings will be reviewed during biweekly supervision sessions. In addition, clinical supervisors will review previous notes and client activity before approving treatment plan updates to ensure Counselor IIIs are followed the agreed upon frequency of sessions as identified and documented on the previous treatment and rehabilitation plan or, adjusted the updated treatment and rehabilitation plan to a more realistic and achievable plan for the Client. Treatment and Rehabilitation Plan updates that are not geared towards the Clients' strengths and realistically achievable by the Client will be rejected and a meeting will be scheduled with the Counselor III to review the proposed plan and discuss how best to meet the Client's needs while providing an appropriate level of care and frequency.
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 (c).
Monitoring: The Site Director will be responsible to provide on-going feedback regarding treatment and rehabilitation management during weekly DA Committee meetings and bi-weekly leadership team meetings with a focus on compliance strategies and measured improvements and outcomes.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information in the client record in four of four applicable client records reviewed. Client # 4 was admitted on August 30, 2019 and was discharged on June 22, 2020. The client record failed to document follow up information regarding the client as of the date of the inspection. Client # 5 was admitted on February 3, 2020 and was discharged on July 7, 2020. The client record failed to document follow up information regarding the client as of the date of the inspection. Client # 6 was admitted on November 18, 2019 and was discharged on August 9, 2020. The client record failed to document follow up information regarding the client as of the date of the inspection. Client # 7 was admitted on August 14, 2019 and was discharged on November 5, 2020. The client record failed to document follow up information regarding the client as of the date of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to comply with regulation 709.93 (a)(11), a brief meeting was held with the Admission and Discharge Department manager today, March 26, to discuss the most efficient way to monitor follow up activities on discharged clients. As a result of this meeting, the Admission and Discharge Department Manager recommended that the Aftercare Plan not be finalized until all scheduled aftercare activities are completed. The current setup, does not allow documenting the follow up once the Aftercare Plan is finalized. In addition, a follow-up progress note will be added to the EHR system that will accept documentation after discharge. The Admission and Discharge Department will assist the therapist in staying on track with the established timeline for Client follow-up after program completion. The Admission and Discharge Department will notify the therapist directly within 72-hours of the needed follow-up, followed by an EHR system reminder within 24-hours of the due date. If the therapist fails to comply and/or is out of the system, the Clinical Supervisor will complete the follow-up, documenting the results in the Client's chart and notifying the therapist in the EHR system of the follow-up activity.
Ongoing monitoring-The Admission and Discharge Manager will perform bi-weekly audits following a baseline audit to ensure that Clients in need of follow-up have been tracked and reported to the Therapist/Clinical Supervisor and have been followed up on according to policy. Report findings will be submitted to the clinical leadership team monthly.
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