INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28, 2021 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 the facility-submitted Staffing Facility Requirements Summary Report and personnel records, the facility failed to ensure that all employees received the minimum of six hours of HIV/AIDS training within the regulatory timeframe.
Employee #2 was hired as a counselor on September 9, 2019 and was due to have the HIV/AIDS training no later than September 9, 2020; however, there was no documentation of the completion of HIV/AIDS in the record as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee in question of this citing has been registered for the HIV/AIDS training requested for October 5-6, 2021.
Director will monitor that the training is completed by observing the completed certificate. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on an administrative review of the May 2020 through June 2021 fire drill log, the facility failed to identify, on their drill log, which exit route was used and the number of persons in the facility at the time of the drill for each fire drill conducted.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PMHC form has been amended to show written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, and the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
Director has already corrected the form to meet the requirements requested.
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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 that a copy of a client consent to release information form was offered to the client in three of four applicable client records reviewed.
Client #1 was admitted on February 24, 2021 and was active at the time of inspection. There were several release of information forms in the record - to a government agency signed and dated by the client on February 24, 2021; to an emergency contact, a hospital, a physician, and a government agency all signed and dated by the client on March 3, 2021; to a government agency signed and dated by the client on April 5, 2021; and to the funding source signed and dated by the client on May 24, 2021. However, there was no documentation, in the record, that copies of any of the release of information forms were offered to the client.
Client #3 was admitted on May 18, 2021 and was active at the time of inspection. A release of information form to a government agency was signed and dated by the client on June 29, 2021 and there was no documentation, in the record, that a copy was offered to the client.
Client #4 was admitted on May 5, 2021 and was discharged on July 2, 2021. A release of information form to a government agency was signed and dated by the client on May 11, 2021 and there was no documentation, in the record, that a copy was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PMHC will add a line to the confidentiality form that offers a client the right to accept or refuse a copy of the form. Both clients have been discharged.
Director will instruct the IT department to include the new line on the confidentiality form.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgment by the client that the client had been informed of their right to retain civil rights and liberties except as provided by statute in three of four applicable client records reviewed.
Client #1 was admitted on February 24, 2021 and was active at the time of inspection.
Client #3 was admitted on May 18, 2021 and was active at the time of inspection.
Client #4 was admitted on May 5, 2021 and was discharged on July 2, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline the clients civil rights. Both clients were discharged.
Director will develop the client handbook and client sign-off sheet that confirms the client was given the orientation to the program @PMHC. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgement by the client that they had been informed of their right that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in three of four applicable client records reviewed.
Client #1 was admitted on February 24, 2021 and was active at the time of inspection.
Client #3 was admitted on May 18, 2021 and was active at the time of inspection.
Client #4 was admitted on May 5, 2021 and was discharged on July 2, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline that PMHC may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. Both clients have been discharged.
Director will develop the client handbook and client sign-off sheet that confirms the client was given the orientation to the program @PMHC. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgment by the client that the client had been informed of their right to inspect their own records in three of four applicable client records reviewed.
Client #1 was admitted on February 24, 2021 and was active at the time of inspection.
Client #3 was admitted on May 18, 2021 and was active at the time of inspection.
Client #4 was admitted on May 5, 2021 and was discharged on July 2, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline that clients have the right to inspect their own records. Both clients have been discharged.
Director will develop the client handbook and client sign-off sheet that confirms the client was given the orientation to the program @PMHC. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgment by the client that the client had been informed of their right to appeal a decision limiting access to their records to the director in three of four applicable client records reviewed.
Client #1 was admitted on February 24, 2021 and was active at the time of inspection.
Client #3 was admitted on May 18, 2021 and was active at the time of inspection.
Client #4 was admitted on May 5, 2021 and was discharged on July 2, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline that clients have the right to appeal a decision limiting access to their records to the director. Both clients have been discharged.
Director will develop the client handbook and client sign-off sheet that confirms the client was given the orientation to the program @PMHC. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgment by the client that the client had been informed of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in three of four applicable client records reviewed.
Client #1 was admitted on February 24, 2021 and was active at the time of inspection.
Client #3 was admitted on May 18, 2021 and was active at the time of inspection.
Client #4 was admitted on May 5, 2021 and was discharged on July 2, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. Both clients have been discharged.
Director will develop the client handbook and client sign-off sheet that confirms the client was given the orientation to the program @PMHC. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgment by the client that the client had been informed of their right to submit rebuttal data or memoranda to their own records in three of four applicable client records reviewed.
Client #1 was admitted on February 24, 2021 and was active at the time of inspection.
Client #3 was admitted on May 18, 2021 and was active at the time of inspection.
Client #4 was admitted on May 5, 2021 and was discharged on July 2, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline that clients have the right to submit rebuttal data or memoranda to their own records. Both clients have been discharged.
Director will develop the client handbook and client sign-off sheet that confirms the client was given the orientation to the program @PMHC. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on review of client records, the facility failed to include, during the intake and admission process, documentation of disclosure to the client of criteria for admission, treatment, completion, and discharge in three of four applicable client records reviewed.
Client #1 was admitted on February 24, 2021 and was active at the time of inspection.
Client #3 was admitted on May 18, 2021 and was active at the time of inspection.
Client #4 was admitted on May 5, 2021 and was discharged on July 2, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline disclosure to the client of criteria for admission, treatment, completion and discharge. Both clients have been discharged.
Director will develop the client handbook and client sign-off sheet that confirms the client was given the orientation to the program @PMHC. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on review of client records, the facility failed to include, during the intake and admission process, documentation of client orientation to the project's policies in three of four applicable client records reviewed.
Client #1 was admitted on February 24, 2021 and was active at the time of inspection.
Client #3 was admitted on May 18, 2021 and was active at the time of inspection.
Client #4 was admitted on May 5, 2021 and was discharged on July 2, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline PMHC client policies. Both clients have been discharged.
Director will develop the client handbook and client sign-off sheet that confirms the client was given the orientation to the program @PMHC. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on review of client records, the facility failed to include, during the intake and admission process, documentation of client orientation to the project's hours of operation in three of four applicable client records reviewed.
Client #1 was admitted on February 24, 2021 and was active at the time of inspection.
Client #3 was admitted on May 18, 2021 and was active at the time of inspection.
Client #4 was admitted on May 5, 2021 and was discharged on July 2, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline PMHC hours of operation. Both clients have been discharged.
Director will develop the client handbook and client sign-off sheet that confirms the client was given the orientation to the program @PMHC. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on review of client records, the facility failed to include, during the intake and admission process, documentation of client orientation to the project ' s fee schedule in three of four applicable client records reviewed.
Client #1 was admitted on February 24, 2021 and was active at the time of inspection.
Client #3 was admitted on May 18, 2021 and was active at the time of inspection.
Client #4 was admitted on May 5, 2021 and was discharged on July 2, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline PMHC client fees. Both clients have been discharged.
Director will develop the client handbook and client sign-off sheet that confirms the client was given the orientation to the program @PMHC. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on review of client records, the facility failed to include, during the intake and admission process, documentation of client orientation to the project ' s provided services in three of four applicable client records reviewed.
Client #1 was admitted on February 24, 2021 and was active at the time of inspection.
Client #3 was admitted on May 18, 2021 and was active at the time of inspection.
Client #4 was admitted on May 5, 2021 and was discharged on July 2, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline, PMHC services provided. Both clients have been discharged.
Director will develop the client handbook and client sign-off sheet that confirms the client was given the orientation to the program @PMHC.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on review of client records, the facility failed to include, during the intake and admission process, documentation of a consent to treatment in three of four applicable client records reviewed.
Client #1 was admitted on February 24, 2021 and was active at the time of inspection.
Client #3 was admitted on May 18, 2021 and was active at the time of inspection.
Client #4 was admitted on May 5, 2021 and was discharged on July 2, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PMHC will have the intake department gain the signature from the client confirming consent to treatment. Both clients have been discharged.
Director will review all client intakes to confirm that clients have signed their consent to treatment. |
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 three applicable client records reviewed.
Client #5 was admitted on November 16, 2020 and discharged on March 9, 2021.
Client #6 was admitted on January 18, 2021 and discharged on May 13, 2021.
Client #7 was admitted on November 30, 2020 and discharged on April 23, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PMHC will institute a spreadsheet documenting client follow-up upon discharge.
Director will review all discharges and that the log documents that client follow-up was completed. |