INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Penn Presbyterian Medical 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
Seven personnel records were reviewed on August 28, 2018. The facility failed to provide documentation of completed HIV/AIDS training for employee record # 3.
Employee # 3 was hired as a counselor on July 3, 2017. The HIV/AIDS training was due to be completed by no later than July 3, 2018. Documentation of this training was not provided by the facility.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Staff Education, Training, and Development policy applicable to the Drug and Alcohol program for inpatients and outpatients (6.00) was reviewed by the Facility and Program Director and Department of Regulatory representatives. The review revealed an opportunity to amend the policy to explicitly indicate mandatory training per the regulations (e.g., HIV/AIDS and STD/TB are mandated to be completed within the first year of hire). The staff person out of compliance will be attending the 6 hour DDAP HIV/AIDS 6-hour training on October 9, 2018. All other staff were assessed to be in compliance at this time.
Completion date: October 9, 2018.
To prevent a re-occurrence, newly hired counselors will be oriented to the requirements of DDAP through a review of the Staff Education, Training, and Development policy (6.00) for the Drug and Alcohol inpatient and outpatient unit as documented on their orientation checklist. The policy specifies that the counselor must have 6 hours of HIVAIDS and STD/TB trainings completed in the first 12 months of employment. Staff attendance and completion of these education requirements will be documented for all new hires by their designated supervisor/manager no more than 1 year from date of hire.
Completion date: November 1, 2018
Methodology for Achieving and Maintaining Compliance:
Completion of new-hire training will be tracked quarterly by the lead supervisor and will continue until four consecutive quarters of sustained compliance. The data will be reported to the Behavioral Health/Drug and Alcohol Unit Based clinical leadership and quality assurance and performance improvement team, as part of the facility's quality assurance and performance improvement activities.. The team will evaluate the results quarterly and implement any further process changes and audits, as needed. The monitoring will begin following completion of staff education.
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
A licensing renewal inspection was conducted on August 28, 2018. Based on a review of the Staffing Requirements Facility Summary Report submitted by the facility during the licensing process, the facility failed to ensure that staff caseloads remain at or under 35:1.
Based on the total number of hours per week devoted to clients, and the standard work week of 35 hours, employee # 7 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by the standard work week of 35 hours.
reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 7 to outpatient client treatment was 10 hours per week. The employee had 12 active clients as of August 23, 2018.
-Employee # 7 (10/35 = .2857 FTE *** 12 clients/.2857 FTE = 42/1 caseload)
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
. To prevent a re-occurrence of this incident, the new clinical lead supervisor, overseeing the counselors, has implemented a program to monitor and record staff hours and current caseload at least quarterly to assure the ratio of 35:1 is maintained and reported accurately.
Completion date: October 19, 2018
Methodology for Achieving and Maintaining Compliance:
Beginning 11/1/2018, compliance for the maximum staffing ratio will be reported quarterly by the lead supervisor for counselors to the Behavioral Health/Drug and Alcohol Unit Based clinical leadership and Quality Assurance Committee, as part of the facility's quality assurance and performance improvement activities. The data will be monitored until compliance is sustained for four consecutive quarters. Leadership will evaluate the results and implement any further process changes and audits, as needed.
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711.91(b)(3)(i) LICENSURE Medical History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Seven client records were reviewed on August 28, 2018. The facility failed to ensure that a complete Biopsychosocial assessment was documented during the intake process for client records # 3 and 7.
Client # 3 was admitted into treatment on January 31, 2018 and was still active in treatment. The Biopsychosocial assessment documented in the client's record was completed on March 15, 2018.
Client # 7 was admitted into treatment on February 8, 2018 and was discharged on June 6, 2018. The Biopsychosocial assessment documented in the client's record was completed on March 29, 2018.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Actions and Proposed Timeframe for Achieving Compliance:
The Intake Policy (1.00) and Biopsychosocial Policy (1.05) were reviewed by the Facility and Program Director and Department of Regulatory representatives. The review revealed an opportunity to amend the policies to state that a complete biopsychosocial assessment with all required fields including the psychosocial evaluation must be included on each patient during the intake process, which is defined as the first 30 days of treatment.
Completion date: October 3, 2018
Unit staff will be re-educated by the clinical supervisor on the revised Intake Policy (1.00) and Biopsychosocial Policy (1.05). Staff attendance and completion of these education requirements will be documented.
Completion date: October 15, 2018.
Methodology for Achieving and Maintaining Compliance:
A quality assurance audit process will be designed to include a review of thirty (30) new admissions (or if less than 30 records are available then the total population) after the first 30 days of treatment. This review will be completed by the clinical supervisor and consist of verifying that all required fields of the biopsychosocial assessment are completed appropriately and within the first 30 days of treatment. Compliance will be tracked monthly, and the audit will continue until three consecutive months of sustained compliance has been achieved. The data will be reported by the clinical supervisor monthly to the Behavioral Health/Drug and Alcohol Unit Based clinical leadership and quality assurance and performance improvement team, as part of the facility's quality Assurance and performance improvement activities. The team will evaluate the results and implement any further process changes and audits, as needed. The audit will begin following completion of staff education.
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711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Seven client records were reviewed on August 28, 2018. The facility failed to ensure that a psychosocial evaluation was documented during the intake process for client records # 3 and 7.
Client # 3 was admitted into treatment on January 31, 2018 and was still active in treatment. The psychosocial evaluation documented in the client's record was completed on March 15, 2018.
Client # 7 was admitted into treatment on February 8, 2018 and was discharged on June 6, 2018. The psychosocial evaluation documented in the client's record was completed on March 29, 2018.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Actions and Proposed Timeframe for Achieving Compliance:
The Intake Policy (1.00) and Biopsychosocial Policy (1.05) were reviewed by the Facility and Program Director and Department of Regulatory representatives. The review revealed an opportunity to amend the policies to state that a complete biopsychosocial assessment with all required fields including the psychosocial evaluation must be included on each patient during the intake process, which is defined as the first 30 days of treatment.
Completion date: October 3, 2018
Unit staff will be re-educated by the clinical supervisor on the revised Intake Policy (1.00) and Biopsychosocial Policy (1.05). Staff attendance and completion of these education requirements will be documented.
Completion date: October 15, 2018.
Methodology for Achieving and Maintaining Compliance:
A quality assurance audit process will be designed to include a review of thirty (30) new admissions (or if less than 30 records are available then the total population) after the first 30 days of treatment. This review will be completed by the clinical supervisor and consist of verifying that all required fields of the biopsychosocial assessment are completed appropriately and within the first 30 days of treatment. Compliance will be tracked monthly, and the audit will continue until three consecutive months of sustained compliance has been achieved. The data will be reported by the clinical supervisor monthly to the Behavioral Health/Drug and Alcohol Unit Based clinical leadership and quality assurance and performance improvement team, as part of the facility's quality Assurance and performance improvement activities. The team will evaluate the results and implement any further process changes and audits, as needed. The audit will begin following completion of staff education.
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711.91(b)(7) LICENSURE Preliminary Treatment Plan
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Seven client records were reviewed on August 28, 2018. The facility failed to ensure that a preliminary treatment plan was documented during the intake process for client records # 3 and 5.
Client # 3 was admitted into treatment on January 31, 2018 and was still active in treatment. A preliminary treatment plan was not documented in the client's record.
Client # 5 was admitted into treatment on May 23, 2018 and was discharged on August 6, 2018. A preliminary treatment plan was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Actions and Proposed Timeframe for Achieving Compliance:
The Preliminary Treatment Plan policy (1.04) was reviewed by the Facility and Program Director and Department of Regulatory representatives. The review revealed an opportunity to amend the policy to state that the preliminary treatment plan must be completed within the first 30 days of treatment.
Completion date: October 3, 2018
Unit staff will be re-educated by the Program Manager or designee on the requirements of the Preliminarily Treatment Plan (1.04). Staff attendance and completion of these education requirements will be documented.
Completion date: October 3, 2018
Methodology for Achieving and Maintaining Compliance:
A quality assurance audit process will be designed to include a review of a thirty (30) new admissions (or if less than 30 records are available then the total population) after the first 30 days of treatment. This review will be completed by the clinical supervisor and consist of verifying that preliminary treatment plans are completed and in the chart within the first 30 days of treatment. Compliance will be tracked monthly, and the audit will continue until three consecutive months of sustained compliance has been achieved. The data will be reported monthly by the clinical supervisor to the Behavioral Health/Drug and Alcohol Unit Based clinical leadership and quality assurance and performance improvement team, as part of the facility's quality assurance and performance improvement activities. The team will evaluate the results and implement any further process changes and audits, as needed. The audit will begin following completion of staff education and no later than 11/1/18.
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