INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 27, 2023 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 of the Alleghenies 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
|
709.92(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 applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in four of six client recordsClient #4 was admitted on June 9, 2022 and discharged on March 28, 2023. A treatment and rehabilitation plan was developed on January 10, 2023. A treatment and rehabilitation plan update was due no later than March 10, 2023, but was not completed until March 21, 2023.Client #5 was admitted on November 30, 2022 and still active at the time of inspection. A treatment and rehabilitation plan was developed on December 15, 2022. A treatment and rehabilitation plan update was due no later than February 15, 2023, but was not completed until March 15, 2023.Client #6 was admitted on September 15, 2022 and still active at the time of inspection. A treatment and rehabilitation plan was developed on January 19, 2023. A treatment and rehabilitation plan update was due no later than March 19, 2023, but was not completed until April 13, 2023.Client #7 was admitted on October 13, 2022 and still active at the time of inspection. A treatment and rehabilitation plan was developed on October 13, 2022. A treatment and rehabilitation plan update was due no later than December 13, 2022, but was not completed until February 13, 2023.A treatment and rehabilitation plan was developed on February 13, 2023. A treatment and rehabilitation plan update was due no later than April 13, 2023, but no treatment plan update was completed at the time of the inspection.This is a repeat citation from May 12, 2022 and June 17, 2021 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Supervisor will complete the "documentation tracker spreadsheet" daily. This spreadsheet tracks when treatment plans were completed and the next due date. Supervisor will provide the staff with a list of treatment plans that have an upcoming due date weekly. This list lists due dates coming up within the next three weeks. Supervisor will review that treatment plan updates are completed in the EMR during the weekly individual staff supervision. Supervisor will also help staff identify any individuals who need to be in the engagement process so that discharges can happen within a timely manner. In addition, Supervisor will receive a monthly plan of care report through EPIC EMR that provides treatment plan compliance percentage. The monthly report breaks down further into treatment plans needing signatures, lapsed treatment plans, no treatment plans, and upcoming treatment plans. If treatment plan compliance is not met, supervisor must create an action plan that is followed by compliance department until compliance is achieved. |
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.
|
Observations
Based on applicable client records reviewed, the facility failed to provide case consultations in accordance with their policy in six of seven client records. The facility's policy states that case consultations are to be completed every sixty days.Client #1 was admitted on June 24, 2022 and discharged on September 20, 2022. A case consultation was due no later than August 24, 2022. No case consultations were found in the record at the time of the inspection.Client #3 was admitted on November 30, 2022 and discharged on February 9, 2023. A case consultation was due no later than January 30, 2023. No case consultations were found in the record at the time of the inspection.Client #4 was admitted on June 9, 2022 and discharged on March 28, 2023. A case consultation was completed on January 10, 2023. A new case consultation was due no later than March 10, 2023, but was not completed until March 21, 2023.Client #5 was admitted on November 30, 2022 and still active at the time of inspection. A case consultation was completed on December 15, 2022. A new case consultation was due no later than February 15, 2023, but was not completed until March 15, 2023.Client #6 was admitted on September 15, 2022 and still active at the time of inspection. A case consultation was completed on January 19, 2023. A new case consultation was due no later than March 19, 2023, but was not completed until April 13, 2023.Client #7 was admitted on October 13, 2022 and still active at the time of inspection. A case consultation was completed on October 13, 2022. A new case consultation was due no later than December 13, 2022, but was not completed until February 13, 2023.A case consultation was completed on February 13, 2023. A new case consultation was due no later than April 13, 2023, but was not completed at the time of the inspection.This is a repeat citation from the May 12, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Supervisor will complete the "documentation tracker spreadsheet" daily. This spreadsheet tracks when case consults were completed and the next due date. Supervisor will provide the staff with a list of case consults that has an upcoming due date weekly. This list lists due dates coming up within the next three weeks. Supervisor will review that case consults are documented in the EMR during the weekly individual staff supervision. Supervisor will also help staff identify any individuals who need to be in the engagement process so that discharges can happen within a timely manner. |
709.11(a) LICENSURE Subchapter B.Licensing Procedures.Application
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
|
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 maintaining compliance with treatment plan update timeframes were submitted and approved by the Department for May 12, 2022 and June 17, 2021 annual licensing inspections. Complying with treatment plan update timeframes was again found to be a deficiency in the April 27, 2023 licensing inspection.This was reviewed with the facility staff during the licensing process.
|
Plan of Correction
On May 24, 2023, program supervisor will reeducate all staff (during all staff meeting) regarding the requirements to ensure all clients have an active and current treatment plan. This education will include that the individual must be present for the development of the initial comprehensive treatment plan; but treatment plan updates can be completed without the individual present in cases where the individual did not attend the session at which the treatment plan update was to occur. In addition, the education will include that if the treatment plan is updated without the individual, it is to be reviewed at the next attended treatment session to ensure person-centered care. Program supervisor will have staff sign off on the treatment plan requirements during staff meeting.
Program supervisor will continue to utilize the updated documentation tracker to track treatment plan due dates. Program supervisor will be responsible to review documentation tracker completion weekly during supervision with staff to check for treatment plan completion. To ensure that these previous POC are followed as summarized above, not only will clinical supervisor discuss during weekly staff meetings, clinical supervisor will have staff complete treatment plan updates with upcoming due dates within one week during weekly supervision if they have not already been completed. the project manager will meet with clinical supervisor weekly to ensure compliance with plan of correction.
|