INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 17, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, UPMC Western Behavioral Health at Mon Yough 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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709.92(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 client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in five of seven applicable records.
Client #1 was admitted on January 30, 2024 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on May 2, 2024. A treatment and rehabilitation plan update was due no later than July 2, 2024, but was not completed until July 9, 2024.
Client #3 was admitted on April 9, 2024 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on May 8, 2024. A treatment and rehabilitation plan update was due no later than July 8, 2024, but was not completed until July 11, 2024.
Client #4 was admitted on February 23, 2024 and was discharged on May 29, 2024. A treatment and rehabilitation plan was developed on March 15, 2024. A treatment and rehabilitation plan update was due no later than May 15, 2024, but was not completed prior to discharge.
Client #6 was admitted on October 10, 2023 and was discharged on March 13, 2024. A treatment and rehabilitation plan was developed on December 7, 2023. A treatment and rehabilitation plan update was due no later than February 7, 2024, but was not completed until February 12, 2024.
Client #7 was admitted on January 17, 2024 and was discharged on May 6, 2024. A treatment and rehabilitation plan was developed on March 5, 2024. A treatment and rehabilitation plan update was due no later than May 5, 2024, but was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A. Re-education, by supervisor, will occur for all staff who complete Treatment Plans, to include therapists and case managers, to review the regulation and internal policy/procedure, to stress the importance of completing Treatment Plans no later than 60 days.
B.The Office Manager will run a report each week from the EMR and inform each clinician via email of upcoming Treatment Plan due dates for every client, to include plans due 60 days out, 30 days out, and past due.
C. Verbal reminders from Supervisor will be given every week at Treatment Team to complete Treatment Plans that are due. Documentation of the verbal reminders will be housed in treatment team notes.
D. Mandatory monthly chart audits will be conducted by peers to ensure that treatment plans are completed timely. If during the chart audit, the staff auditor identifies a missing treatment plan, they will notify the clinician and supervisor immediately to complete the treatment plan.
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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 client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in three of seven applicable records. The facility policy and procedure manual indicate a case consultation to occur every four months.
Client #1 was admitted on January 30, 2024 and was still active at the time of the inspection. A case consultation occurred on February 6, 2024. A case consultation was due to occur no later than June 6, 2024, but was not completed until August 7, 2024.
Client #2 was admitted on March 28, 2024 and was still active at the time of the inspection. A case consultation occurred on April 4, 2024. A case consultation was due to occur no later than August 4, 2024, but was not completed until August 8, 2024.
Client #6 was admitted on October 10, 2023 and was discharged on March 13, 2024. A case consultation was due to occur no later than February 10, 2024, but was not completed until February 15, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A. Re-education, by supervisor, will occur for all staff of the agency policy/procedure to review that Case Consultation Notes must be completed no later than 120 days.
B. Clinicians will check their client records at each Treatment Plan review to determine when Case Consultation notes are due. Clinicians will complete them on time.
C. Anytime a consult occurs pertaining to client progress, needs, challenges, etc. the clinician will complete a Case Consultation note. This includes, but not limited to, individual supervision, group supervision, treatment team, peer to peer consults, etc.
D. Mandatory monthly chart audits will be conducted by peers to ensure that case consultations are completed timely. If during the chart audit, the staff auditor identifies a missing case consult, they will notify the clinician and supervisor immediately to complete the case consult.
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