INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 20, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Penndel Mental 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in two of two applicable personnel record reviewed.
Employee #3 was hired as a counselor on November 21, 2022 and was due to receive both the HIV/AIDS training and the TB/STD training no later than November 21, 2023. The TB/STD training was completed on June 7, 2024.
Employee #4 was hired as a counselor on May 1, 2023 and was due to receive both the HIV/AIDS training and the TB/STD training no later than May 1, 2024. The TB/STD training was completed on May 7, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Penndel Mental Health Center will alter training plan format to include mandatory trainings upon hire including TB/STD and will monitor during supervisions to ensure all new hires complete all mandatory trainings within their first year of employment. Director will be responsible for implementation of this plan of correction. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, the facility failed to ensure that a sufficient number of staff persons were certified in CPR and first aid trained, so that at least one person trained in these skills was onsite during the project's hours of operation.
The facility provided documentation that only one employee had current CPR certification and first aid training. The facility's hours of operation are Monday through Friday from 8:00am to 4:00pm; however, one employee is not sufficient to provide CPR and first aid coverage for the documented hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Penndel Mental Health Center will be sending 2-3 employees for CPR/First Aid training to be completed no later than 9/30/2024
The director of the program will monitor on a quarterly basis the number of current employees certified and send staff for training/certification as necessary.
Director will be responsible for implementation of this plan of correction. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on a release of information form in one of seven client records reviewed.
Client #2 was admitted on December 15, 2023 and was active at the time of the inspection. A blank release of information form was signed and dated by the client on April 11, 2024; however, the name of the person, agency, or organization to whom the disclosure was to be made was not documented on the form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Penndel Mental Health Center has complete retraining on completing releases of information with the current staff member who failed to complete the release for client #2 correctly. Moreover, Penndel Mental Health Center will be including all releases of information into chart audits moving forward.
Director will be responsible for implementation of this plan of correction. |
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 the disclosure on a consent to release information form in one of seven client records reviewed.
Client #2 was admitted on December 15, 2023 and was active at the time of the inspection. A blank release of information form was signed and dated by the client on April 11, 2024; however, the purpose of the disclosure was not documented on the form.
This is a repeat citation from the May 24, 2022 and July 6, 2023 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PMHC has providing retraining for the staff member who failed to complete roi for client #2 correctly. PMHC will be including all ROIs in chart audits moving forward.
Director will be responsible for implementation of this plan of correction. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which a consent to release information form will expire in two of seven client records reviewed.
Client #2 was admitted on December 15, 2023 and was active at the time of the inspection. A blank release of information form was signed and dated by the client on April 11, 2024; however, the date, event, or condition upon which the consent will expire was not documented on the form.
Client #5 was admitted on November 6, 2023 and was discharged on March 19, 2024. A release of information form to another treatment provider was signed and dated by the client on February 27, 2024; however, the date, event, or condition upon which the consent will expire was not documented on the form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PMHC has providing retraining for the staff member who failed to complete roi for client #2 correctly including expiration date. PMHC will be including all ROIs in chart audits moving forward. Lastly, PMHC will be reviewing policies and procedures around expiration dates for releases of information.
Director will be responsible for implementation of this plan of correction. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure a copy of a consent to release information form was offered to the client in one of seven client records reviewed.
Client #2 was admitted on December 15, 2023 and was active at the time of the inspection. A blank release of information form was signed and dated by the client on April 11, 2024; however, there was no documentation that the release form was offered to the client.
This is a repeat citation from the July 28, 2021, May 24, 2022, and July 6, 2023 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PMHC has providing retraining for the staff member who failed to complete roi for client #2 correctly including the need to reflect whether a copy of consent was offered to client and outcome. PMHC will be including all ROIs in chart audits moving forward. PMHC will also review EHR to see if this field can be made a required field to avoid this issue in the future.
Director will be responsible for implementation of this plan of correction. |
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 ensuring the client is offered a copy of a consent to release information form were submitted and approved by the Department for the May 24, 2022, July 28, 2021, and July 6, 2023 annual licensing inspections. Documentation that a copy of consent to release information forms were offered to the client was again found to be a deficiency in the June 20, 2024 licensing inspection.
Plans of correction for ensuring the purpose of the disclosure was documented on a consent to release information form were submitted and approved by the Department for the May 24, 2022 and July 6, 2023 annual licensing inspections. Ensuring the purpose of the disclosure was included on consent to release information forms was again found to be a deficiency in the June 20, 2024 licensing inspection.
This is a repeat citation from the July 6, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PMHC will be reviewing EHR to see if this field can be made a required field to avoid this issue in the future. If this is possible, it will be altered to be required. Moreover, PMHC will be including all ROIs in chart auditing moving forward.
Director will be responsible for implementation of this plan of correction. |