INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 5, 2022 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:
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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 a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of seven client records reviewed.Client #4 was admitted July 14, 2021 and was discharged December 30. 2021. A treatment plan update was completed on August 24, 2021 and the next update was due no later than October 24, 2021. However, the update was not completed prior to discharge. Client #5 was admitted March 8, 2022 and was discharged August 8, 2022. The comprehensive treatment plan was completed on March 8, 2022 and the first update was due no later than May 8, 2022. However, the update was not completed prior to discharge.Client# 6 was admitted December 4, 2020 and was discharged February 1, 2022. A treatment plan update was completed on October 4, 2021 and the next update was due no later than December 4, 2021. However, the update was not completed prior to discharge.Client # 7 was admitted June 22, 2020 and was discharged March 4, 2022. A treatment plan update was completed on September 28, 2021 and the next update was due no later than November 28, 2021. However, the update was not completed prior to discharge.The findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
709.92 (b) ? Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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.
Additionally, training and support will be provided to counselors as needed.
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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 the review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in three of seven client records reviewed. Client #1 was admitted June 25, 2021 and was active at the time of inspection. The comprehensive treatment and rehabilitation plan was dated July 11, 2022 and indicated that the client was to receive bi-weekly individual sessions. There was no documentation, in the record, of any individual sessions provided to the client since July 11, 2022.Client #5 was admitted March 8, 2022 and was discharged August 8, 2022. The comprehensive treatment and rehabilitation plan was dated March 8, 2022 and indicated that the client was to receive bi-weekly individual sessions. There was no documentation, in the record, of any individual sessions provided to the client since March 8, 2022.Client# 6 was admitted December 4, 2020 and was discharged February 1, 2022. The comprehensive treatment and rehabilitation plan was dated October 4, 2021 and indicated that the client was to receive bi-weekly individual sessions. There was no documentation, in the record, of any individual sessions provided to the client since October 4, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92 (c) ? The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
In an effort to reestablish and maintain compliance as it relates to Standard 709.92 (c), the following corrective action plan has been put in place.
The Counselor and client will meet to discuss the counseling services to be provided in their individual treatment and rehabilitation plan. Counselor will ensure that services are rendered as indicated and agreed upon in the treatment and rehabilitation plan, and document accordingly. Counselor will document all services in accordance with the individual's treatment and rehabilitation plan, whether the client attends or fails to attend. If client is unable to meet the agreed upon schedule of services in accordance with the treatment and rehabilitation plan, Counselor and client will update the treatment and rehabilitation plan to an agreed upon course of treatment.
Ongoing monitoring of compliance.
Clinical Supervisors will provide bi-weekly supervision to Counselors to ensure an understanding of Compliance with 709.92 (c). Clinical Supervisors will audit charts and review treatment plans weekly to ensure compliance with 709.92 (c).
The Site Director will be responsible for ongoing monitoring of the Clinical Supervisors to ensure that counseling services are provided according to the individual's treatment and rehabilitation plan.
QA will audit treatment and rehabilitation plans to assess the accuracy and compliance of treatment frequency and agreed upon services and supported documentation. Results will be presented during the monthly all staff meeting and site leadership meeting.
Additionally, training interventions and support will be provided to counselors as needed to bring the accuracy of treatment and rehabilitation planning to an acceptable compliance of 100%. |