INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 26, 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, GPHA A1-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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, conducted 9/26/17 at approximately 1:00 p.m., it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room as an individual counseling session being conducted in Room 309 could be overheard in the hallway. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Standard in Noncompliance
705.23 CONFIDENTIALITY:
In an effort to achieve and maintain full compliance with regulation 705.23, the findings from the September 26, 2017, were reviewed by the Chief Behavioral Healthcare Officer and Clinical Team, CEO/Executive Director and Director of Maintenance. As a result of the findings and full review of recent construction on the 3rd floor. The following corrective action plan was immediately implemented.
As an overhead barrier, insulation rolls have been added to the entire 3rd floor drop ceilings to reduce sound travel.
In-addition, Therapist found to have their Sound reduction machine in their office were instructed to place the sound reduction machines outside of their office nearest to the wall and clear of possible tripping to reduce sound travel.
Correction Time: Correction completed. Monitoring of Sound reduction machines will be on-going and has been added to the Security Guards' 30-Minute walk-through checklist |
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 seven client records, five records had treatment plan updates that were either completed after the regulatory timeframe or missing at the time of the inspection.Client #1 was admitted on 12/6/16 and was an active patient at time of inspection. A treatment plan update was completed 2/27/17 and the next update was due no later than 4/27/17. However, the update was not completed until 5/25/17.Client #2 was admitted on 9/19/16 and was an active patient at time of inspection. A treatment plan update was completed 1/10/17 and the next update was due no later than 3/10/17. However, the update was not completed until 4/18/17.Client #3 was admitted on 11/18/16 and was an active patient at time of inspection. A treatment plan update was completed 3/22/17 and the next update was due no later than 5/22/17. However, the update was not completed until 8/3/17.Client #4 was admitted on 2/21/17 and was discharged on 9/13/17. A treatment plan update was completed 3/23/17 and the next update was due no later than 5/23/17. However, the update was not completed at the time of inspection.Client #7 was admitted on 9/8/15 and was discharged on 3/8/17. A treatment plan update was completed 3/23/16 and the next update was due no later than 5/23/16. However, the 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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