This report is the result of a Department of Human Services, Chapter 5100 Mental Health Procedures Act Survey conducted on March 1, 2019 at Excela Health Latrobe Hospital. It was determined the facility was not in compliance with requirements of the Chapter 5100 Mental Health regulations.
Plan of Correction:
5100.15 (2) REQUIREMENT
Treatment Plan Content and Availability
Name - Component - 00
5100.15 CONTENTS OF TREATMENT PLANS
(a) A comprehensive individualized plan of treatment shall:
(2) Be based upon diagnostic evaluation which includes examination of the medical, psychological, social, cultural, behavioral, familial, educational, vocational, and developmental aspects of the patients situation.
Based on review of facilty documentation, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure a comprehensive individualized plan of treatment was based upon medical and psychological aspects of the patients situation for two of three medical records reviewed (MR1 and MR2).
Review of facility policy, Treatment Plans and Reviews, last reviewed May 2016, revealed, "...Procedure: ... 5. Treatment plans will be reviewed by the Treatment Team on Tuesday and Friday each week. If new problems arise, then new goals will be initiated. ... "
Review of MR1 on March 1, 2019, revealed documentation and a physician order for locked seclusion on March 2, 2018. Further review of MR1 Treatment Plan revealed no documentation for a goal or plan for locked seclusion.
Review of MR2 on March 1, 2019, revealed documentation and a physician order for locked seclusion on April 24, 2018. Further review of MR1 Treatment Plan revealed no documentation for a goal or plan for locked seclusion.
Interview with EMP1 on March 1, 2019, at 1:20 PM confirmed the above findings.
Plan of Correction:
By 3/31/2019, the Behavioral Health Policy, Treatment Plans and Reviews will be reviewed and revised. Staff will be educated by the Clinical Director on the policy revisions and re-educated on charting requirements for Electronic Ad hoc form "Initiation of Violent Self Destructive Behavioral Restraints". To monitor compliance with the policy and documentation, the Clinical Director will conduct an audit of 100% of the records of patients who require seclusion during this time frame will take place during the months of April, May and June 2019. The review will verify that treatment plan goals were updated within 24 hours of initiation of seclusion. Areas of opportunity will be addressed immediately by the manager. A report on findings will be presented to the Department of Behavioral Health Provider Meeting in July 2019.