INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 1, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the policy and procedure manual and client records, the facility failed to follow three of their own specific written procedures for the management of treatment and rehabilitation services in seven of seven client records reviewed.1.The policy and procedure manual stated that the program will complete a biopsychosocial evaluation within 45 working days of admission. Client #1 was admitted on January 12, 2023 and was active at the time of inspection. The biopsychosocial evaluation was due no later than March 3, 2023; however, the evaluation was completed on July 28, 2023.Client #2 was admitted on November 21, 2022 and was active at the time of inspection. The biopsychosocial evaluation was due no later than January 17, 2023; however, the evaluation was completed on May 4, 2023.2.The policy and procedure manual stated that the program will complete an initial treatment and rehabilitation plan within 15 working days of admission.Client #3 was admitted on April 5, 2023 and was active at the time of inspection. The initial treatment and rehabilitation plan was due no later than April 26, 2023; however, the treatment plan was completed on May 16, 2023Client #5 was admitted on March 9, 2023 and was discharged on July 7, 2023. The initial treatment and rehabilitation plan was due no later than March 30, 2023; however, the treatment plan was completed on July 7, 2023.3.The policy and procedure manual stated that the program will complete a discharge summary within 7 days of discharge.Client #4 was admitted on January 10, 2023 and was discharged on May 10, 2023. The discharge summary was due no later than May 17, 2023; however, the summary was completed on June 28, 2023.Client #6 was admitted on December 2, 2019 and was discharged on May 1, 2023. The discharge summary was due no later than May 8, 2023; however, the summary was completed on June 15, 2023.Client #7 was admitted on October 26, 2017 and was discharged on February 16, 2023. The discharge summary was due no later than February 23, 2023; however, the summary was completed on March 31, 2023.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
709.24 (a) (3) LICENSURE
Treatment/rehabilitation management.:
To establish and maintain compliance with § 709.24. Treatment/rehabilitation management in accordance with our own specific written policies and procedures for the management of treatment and rehabilitation, the following corrective action has been implemented:
We initiated a comprehensive review of our current policies and protocols. Our objective was to ensure our current treatment and rehabilitation management practices are aligned with DDAP requirements, ASAM's best practice standards, and are realistic.
We identified the gaps in compliance by tracing the charts reviewed focusing on how, when, and why they occurred and established immediate corrective actions to avoid future non-compliance related to established timelines for completing treatment task and rehabilitation management.
Additionally, a thorough training session is scheduled for September 15, 2023, to ensure that all drug and alcohol staff members are fully informed and knowledgeable about the policies and procedures related to the management of treatment and rehabilitation services. We will reinforce the importance of strict adherence to these guidelines specifically timelines. This training session will also include a peer review and discussion on findings and treatment strategies to improve outcomes and clinical documentation.
Monitoring:
On-going monitoring for compliance will occur bi-weekly by the DA Committee. Clinical Supervisors will review charts weekly to monitor and ensure compliance with treatment and rehabilitation management. The Admission and Discharge Dept. will communicate daily with the Site Directors and Clinical Supervisors to ensure that established timelines during admission and discharge are adhered to according to policies and procedures. The Site Director and Quality Assurance Manager will report findings from compliance audits to the BH Leadership Team quarterly to track trends in compliance and identify any area in need of an alternative 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.
|
Observations
Based on a review of client records, the facility failed to document the specific information to be released on consent to release information forms in one of seven client records reviewed. Client #5 was admitted on March 9, 2023 and was discharged on July 7, 2023. A release of information form to an emergency contact was signed and dated by the client on March 9, 2023; however, the specific information to be disclosed was not included on the form.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction:
709.28 (c) (2) LICENSURE
Confidentiality:
In an effort to comply with § 709.28. Confidentiality. A meeting was held with the individual that failed to meet confidentiality compliance on August 2, 2023. The purpose of this meeting was to ensure that a clear understanding of § 709.28. was obtained and to identify how the employee was able to complete/submit the Consent Form in the EHR system and bypass the required field of Information to Disclose. During this tracer, we discovered the gap in compliance and made the following correction.
The Program type field was made a required field as well, which enforces § 709.28 full compliance. Changing this field to required blocks counselors from submitting the form without completing all required fields which supports the confidentiality release of information guidelines.
Active clients informed and voluntary consent forms are under review. Active Clients with other identified on their informed and voluntary consent form will be asked to review, approve, and sign an updated consent form to specific information to disclose.
Ongoing monitoring-DA Clinical Supervisors/Coordinators will monitor active Clients over the next 30-days to ensure all informed and voluntary consent forms are in compliance. The Admission and Discharge Manager will perform bi-weekly audits of new admits ensuring that the informed and voluntary consent forms are completed according to standards. Findings from the audit will be presented quarterly to the BH Leadership Team.
|
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.
|
Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in five of five applicable client records reviewed. Client #1 was admitted on January 30, 2023 and active at the time of inspection. The initial treatment and rehabilitation plan was completed on January 30, 2023, and the first update was due no later than March 30, 2023; however, the update was completed on May 17, 2023.Client #2 was admitted on November 21, 2022 and active at the time of inspection. The initial treatment and rehabilitation plan was completed on November 21, 2022, and the first update was due no later than January 21, 2023; however, the update was completed on July 19, 2023.Client #3 was admitted on April 5, 2023 and active at the time of inspection. The initial treatment and rehabilitation plan was completed on May 16, 2023, and the first update was due no later than July 16, 2023; however, the update was completed on July 25, 2023.Client #6 was admitted on December 2, 2019 and was discharged on May 1, 2023. A treatment plan update was completed on November 2, 2022, and the next update was due no later than January 2, 2023; however, the update was completed on April 14, 2023.Client #7 was admitted on October 26, 217 and was discharged on February 16, 2023. A treatment plan update was completed on October 12, 2022, and the next update was due no later than December 12, 2022; however, the update was not completed prior to discharge.This is a repeat citation from the October 5, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
709.92(b) LICENSURE
Treatment and rehabilitation services:
Plan of Correction:
In an effort to comply with Standard 709.92(b) Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
Clinical Supervisors will monitor the DA Compliance Tracker weekly to identify Members with Treatment and Rehabilitation Plans that are approaching the 60-day review date and coordinate the due date in advance with the Counselor and Member.
Treatment and Rehabilitation Plans for Drug and Alcohol members will no longer be driven by regularly scheduled appointments but developed and processed based on the treatment and rehabilitation plan update due date. All efforts will be made to coordinate with the members in advance to obtain input and signatures.
Treatment and Rehabilitation Updates will be finalized electronically every 60-days providing day 60 falls on a workday. In the event of day 60 falling outside of a scheduled workday, the Treatment and Rehabilitation Plan will be finalized within 24 hours of the scheduled Treatment and Rehabilitation Plan Update due date.
An addendum to information in the Treatment and Rehabilitation Plans may occur after the finalized Treatment and Rehabilitation Plan Update at the request of the Member, Counselor, or Clinical Supervisory Team.
Information regarding Treatment and Rehabilitation Plan Addendum and Finalization Process was added to the Treatment and Rehabilitation Plan Policy and reviewed with the Policy and Procedure Sub-Committee on Friday, July 7, 2023.
ALL Clinical Staff received a copy of the revised policy with the revisions highlighted on Monday, July 10, 2023. Formal training of the revision took place on July 18, 2023. A review/reminder of the expectations for treatment and rehabilitation plan update compliance occurred during the all staff meeting on August 25, 2023.
On-going Monitoring:
Supervisors will monitor treatment and rehabilitation plans weekly using the DA tracker to identify upcoming Treatment and Rehabilitation Plans that are due for a 60-day Update until the member has satisfied the requirements for program discharge.
The QA Department will continue to reconcile the treatment and rehabilitation plan audits weekly to identify treatment plan update completion and those in need of completion based on scheduled appointments.
The Site Director will be responsible for weekly monitoring of the Clinical Supervisors compliance with tracking DA services and to ensure that quality services are being provided based on the level of care and treatment outlined in the treatment and rehabilitation plan.
The QA Manager will audit treatment and rehabilitation plans for compliance with 709.92 (b) and for clinical soundness. Aggregate findings per location, per supervisor, per counselor will be reported to the BH Leadership Team Monthly and Quarterly to the Executive Staff. The purpose of pulling aggregate data on each site and employees is to identify gaps in care and to identify if additional training is needed on a site level or individual level.
|
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.
|
Observations
Based on a review of client records, the facility failed to ensure counseling services were being provided according to the individual treatment and rehabilitation plan in two of five applicable client records reviewed. Client #2 was admitted on November 21, 2022 and was active at the time of inspection. The individual treatment and rehabilitation plan, dated November 21, 2022, indicated group and individual weekly counseling services. There was no documentation of group counseling services throughout the treatment episode and there was no documentation of individual counseling services occurring during the weeks of February 12, 2023 - March 11, 2023.Client #3 was admitted on April 5, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan, dated May 16, 2023, indicated individual weekly counseling services. There was no documentation of individual counseling services occurring during the weeks of May 7, 2023 - June 17, 2023.This is a repeat citation from the October 5, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction:
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.
To comply with 709.92. (c) Treatment and rehabilitation services, the following measures have been put in place to ensure that counseling services are provided according to the individual treatment and rehabilitation plan.
Clinical Supervisors will ensure that frequency of individual and group sessions are added to the DA tracker to monitor treatment scheduling compliance based on the proposed treatment frequency. The clinical supervisor will monitor the DA Tracker weekly to ensure compliance of treatment frequency.
Clinical Counselors who fail to schedule according to the proposed treatment frequency will be reminded immediately of the need to schedule appointments as outlined in the approved treatment and rehabilitation plan.
Members who are scheduled according to the proposed treatment frequency and fail to attend the scheduled treatment session will receive follow-up to identify the causal factor(s) for the missed appointment and to reschedule the missed appointment. If the member continues to miss scheduled appointments despite efforts to encourage full treatment participation, an addendum to the treatment and rehabilitation plan will be made to align with the Members current ability to actively participate in treatment.
On-going Monitoring:
Supervisors will monitor treatment and rehabilitation plan (treatment frequency) weekly using the DA tracker to identify scheduling and participation compliance with Treatment and Rehabilitation Plan identified treatment frequency.
The Site Director will be responsible for weekly monitoring of the Clinical Supervisors compliance with tracking DA services and to ensure that quality services are being provided based on the level of care, treatment frequency, and treatment outlined in the treatment and rehabilitation plan.
The Site Director will be responsible for reporting on the findings of the DA Tracker in monthly site meetings. Aggregate findings will be reported to identify gaps in care and to identify if additional training is needed on a site level or individual level.
|