INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the 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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704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Based on a review of personnel records, the facility failed to document training subject areas that are based on previous education, experience, current job functions, and job performance on individual training plans in two of six personnel records reviewed. Employee #1 was hired as the project director on January 15, 2018. The individual training plan, completed on December 3, 2021, did not document any training subject areas. Employee #2 was hired as the facility director on June 1, 2019. The individual training plan, completed on December 1, 2021, did not document any training subject areas.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to comply with regulation 704.11. Staff development program. (b) Individual training plan. The staff development plans determined inefficient during the audit were revised on June 20, 2022, to include specific subject areas based upon previous education, experience, current job functions, and job performance.
Ongoing monitoring of Staff Development Plans will be audited for compliance upon completion based on Standard 704.11. Staff Development Program to ensure that the completed staff development plan meets all sections of Standard 704.11.
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all facility heaters were permanently mounted or installed as a space heater was located in room 120, which is a counselor's office.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to comply with Standard 705.26. Heating and cooling. A review of Standard 705.26 and GPHA's current policy on safety hazards which includes but is not limited to prohibited use of personal space heaters in the workplace was conducted with all behavioral healthcare employees on June 17, 2022. In addition, GPHA's current policy is up for review on July 5, 2022, with the policy and procedure sub-committee to include language for aggressive disciplinary action for violation/policy infractions. Approved revisions will be made during the meeting and forwarded to the policy and procedure committee for final approval. The revised policy will be sent to BH employees for review in GPHA's University on July 8, 2022.
On-going monitoring of Standard 705.26. Heating and Cooling will be conducted daily during facility safety and environment of care walkthroughs. Findings from daily walkthroughs are recorded on the security walkthrough form, maintained in the site-walkthrough safety binder, and readily available for review. Identified safety concerns are escalated to the appropriate department for correction. Security officers will immediately remove off premises without exception any personal heating or cooling appliance/unit. Security officers will notify the Site-Director of any infractions and complete an incident report. The incident report will be sent to Corporate Compliance and Site Director for review and corrective action.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on release forms in two of seven client records reviewed. Client #1 was admitted on January 3, 2022 and was active at the time of inspection. A release of information form to the funding source, signed and dated by the client on April 4, 2022, did not specify the purpose of disclosure as the purpose only stated " other. "Client #2 was admitted on January 4, 2022 and was active at the time of inspection. A release of information form to the emergency contact, signed and dated by the client on January 4, 2022, did not specify the purpose of disclosure as the purpose only stated " other. "These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.28 (c) (3) LICENSURE
Confidentiality:
In an effort to comply with § 709.28. Confidentiality. (c) The option to select other was removed from the informed and voluntary consent form on 6/29/2022. The remaining options for purpose of disclosure are: authorize care, facilitate claims, monitor services, continuity of care, transfer of service, SSI/SSDI review, court/treatment compliance, and family/collateral family compliance. If the purpose of disclosure fails to fall under the listed categories, therapist will be required to submit a field request form to the Site Director and EHR Specialist to add an additional category. Once the additional category has been approved and added. The therapist will then complete the informed and voluntary consent form with the client during their next scheduled appointment.
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 reason for the disclosure.
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 to ensure 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.
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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 of client records, the facility failed to document the date of the client signature on release of information forms in seven of seven client records reviewed.Each release of information form in every client record reviewed had the client's signature documented; however, there was no date of the signature documented.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.28 (c) (4) LICENSURE
Confidentiality:
In an effort to comply with § 709.28. Confidentiality. (c) (4) The Signature date for the client/guardian has been added as a separate mandatory field on the informed and voluntary consent form for the disclosure of information contained in the client record effective 6/29/2022. Active clients informed and voluntary consent forms are under review. Active Clients without the date indicating when the informed and voluntary consent form was signed will be asked to review, approve, sign and date an updated consent form to indicate the date of the revised informed and voluntary consent form.
Ongoing monitoring-DA Clinical Supervisors/Coordinators will monitor active Clients over the next 30-days to ensure all informed and voluntary consent forms contain the Clients signature and date. The Admission and Discharge Manager will perform bi-weekly audits of new admits to ensure 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.
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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 two of five applicable client records reviewed.Client #2 was admitted on January 4, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on January 4, 2022 and the first update was due no later than March 4, 2022; however, the update was not completed until April 21, 2022. Client #5 was admitted on February 5, 2021 and was discharged on September 16, 2021. A treatment plan update was completed on June 24, 2021 and the next update was due no later than August 24, 2021; 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
The Counselors and Clients will be required to have an onsite face-to-face visit between the fiftieth and fifty-eight days of a treatment plan update. The counselor will review daily treatment plan audits provided by the Quality Assurance Department and prepare to schedule onsite visits and update treatment plans. Counselors must complete the treatment plan update regardless of the Client's attendance or participation. Clients who fail to keep their scheduled appointment before the required update will be instructed to review the treatment plan update at their next appointment. No adjustments to the existing plan will be made to avoid an automatic electronic submission date change in the EHR record. Client comments regarding the treatment plan will be documented in the progress note. If the Client disagrees with the completed treatment plan update, a new treatment plan update will be developed to accommodate the recommended changes and agreed-upon treatment.
Ongoing monitoring of compliance.
The QA Department will reconcile the treatment plan audits weekly to identify treatment plan update completion and those in need of completion.
Clinical Supervisors will monitor the quality assurance reports for compliance. Clinical Supervisors will review completed treatment plans for compliance weekly.
The site Director will be responsible for ongoing monitoring of the Clinical Supervisors to ensure the treatment plan audit reports are being reviewed and client records are in compliance with standard 709.92 (b).
The QA Manager will audit treatment rehabilitation plans for compliance and report on the aggregate findings per counselor, per location Monthly and quarterly. Additional training and support will be provided to counselors as needed.
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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 a maintain a complete client record on an individual, which is to include follow-up information, in three of four applicable client records reviewed.Client #5 was admitted on February 5, 2021 and discharged on September 16, 2021. Client #6 was admitted on July 30, 2021 and discharged on August 26, 2021. Client #7 was admitted on August 9, 9021 and discharged on September 9, 2021.This is a repeat citation from the June 16-17, 2021 and February 9, 2021 annual licensing renewal inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.93(a)(11) LICENSURE
Client records:
In an effort to comply with 709.93. Client records (a) (11) follow-up information the following process has been put in placed based on current hybrid staffing model, telehealth, and being extremely short staffed. The EHR Specialist is developing a single follow-up information tracking form within the EHR system to capture all follow-up attempts including secure standardized emails, patient portal notifications, phone calls, and automated text messaging. Read/Write status for the follow-up information form will be available for support and clinical staff. Timely and/or Targeted follow-up will occur at maximum daily at minimum monthly by selected support staff and clinical staff.
The current follow-up policy is being revised to include referenced to the EHR follow-up tracking form, use of the patient portal, secure email, and automated text. The revised policy will be presented to the policy sub-committee for review and to the policy committee for final approval. Development of the EHR follow-up tracking form and policy revision, review, and approval will be completed by July 20, 2022.
Ongoing monitoring of follow-up will be completed through EHR generated reports based on missed appointments and non-service encounters in >15 days. The Admission and Discharge Department will monitor and complete any needed follow-up based on the EHR generated reports and document accordingly.
AD Manager will review the EHR generated follow-up report for reconciliation and report the aggregated findings in monthly leadership meeting.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. Plans of correction for follow-ups were submitted and approved by the Department for the June 16-17, 2021 and February 9, 2021 annual licensing inspections. Not documenting follow-up information was again found to be a deficiency in the June 1, 2022, licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
709.17. Refusal or revocation of license. (3) Failure to comply with a plan of correction approved by the Department.
The pervious plan of correction for 709.93- Follow-up information was not consistently followed based on staff turnover, limited staffing and workflow changes.
In an effort to comply with 709.93. Client records (a) (11) follow-up information the following process has been put in placed based on current hybrid staffing model, telehealth, and being extremely short staffed. The EHR Specialist is developing a single follow-up information tracking form within the EHR system to capture all follow-up attempts including secure standardized emails, patient portal notifications, phone calls, and automated text messaging. Read/Write status for the follow-up information form will be available for support and clinical staff. Timely and/or Targeted follow-up will occur at maximum daily at minimum monthly by selected support staff and clinical staff.
The current follow-up policy is being revised to include referenced to the EHR follow-up tracking form, use of the patient portal, secure email, and automated text. The revised policy will be presented to the policy sub-committee for review and to the policy committee for final approval. Development of the EHR follow-up tracking form and policy revision, review, and approval will be completed by July 20, 2022.
Ongoing monitoring of follow-up will be completed through EHR generated reports based on missed appointments and non-service encounters in >15 days. The Admission and Discharge Department will monitor and complete any needed follow-up based on the EHR generated reports and document accordingly.
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