INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14-17, 2019, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Psychiatric Institute 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The group room next to the staff break room had a door with a window that allows people to see into the group room.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Privacy frosting put on windows surrounding group therapy room on March 5, 2019.
The Project Director and Site Manager will ensure that all rooms, including the group therapy room, within the site that have any potential visibility will have appropriate window treatments that protect the privacy and confidentiality of the patients.
In addition, all visibility areas that have the potential of exposing patient confidentiality, will be monitored monthly on safety and security rounds conducted by site delegated safety officer. All deficiencies will be addressed within 72 hours. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct fire drills in the months of June, July, August, September, November and December in the year 2018.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
HOW:
1.Changed process and procedures from the Joint Commission regulations and requirements to DDAP's regulations and requirements.
2.Monthly safety auditing template changed to reflect DDAP regulations and requirements. .
WHEN:
1.Fire drill report form edited to reflect DDAP's regulations on January 17, 2019.
2.Safety rounding tool revised January 17th, 2019.
3.All staff educated about elements of a valid fire drill on March 7, 2019.
WHO:
1.Program Director, Stephanie Kegel, will ensure that processes are being followed through a monthly review of Safety Rounds auditing that is documented with the organization's Head of Security and the organization's Safety Officer.
2.Safety rounding audit results reported quarterly to the Quality Committee of the Board.
3.If compliance falls below threshold for more than 3 months, the area in need of improvement will be sent to the Performance Improvement Committee to receive priority attention for improvement.
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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
The facility's fire drill records did not document all of the required information.
The fire drill log for October 17, 2018, did not include the evacuation route used in the fire drill.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Changed process and procedures to reflect state requested format versus the Joint Commission format.
Fire drill report form edited to reflect DDAP regulations on January 17, 2019. All staff educated about elements of a valid fire drill on March 7, 2019.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
The facility failed to follow its written procedures for the management of treatment/rehabilitation services for patients in 7 of 10 applicable patient records reviewed during the on-site inspection. A total of 14 patient records were reviewed during the on-site inspection.
According to the facility's policy and procedures #2.15 section B3(b), the initial comprehensive treatment plan is to be completed within 30 days of admission.
Patient #2 was admitted for treatment on December 5, 2018, but the patient's individualized treatment plan was not completed at the time of the on-site inspection.
Patient #3 was admitted for treatment on July 6, 2018, but the patient's individualized treatment plan was not completed until September 5, 2018.
Patient #4 was admitted for treatment on July 10, 2018, but the patient's individualized treatment plan was not completed until September 13, 2018.
Patient #8 was admitted for treatment on October 2, 2018, but the patient's individualized treatment plan was not completed at the time of the on-site inspection.
Patient #9 was admitted for treatment on June 22, 2018, but the patient's individualized treatment plan was not completed until August 9, 2018.
Patient #13 was admitted for treatment on September 10, 2018, but the patient's individualized treatment plan was not completed until October 17, 2018.
Patient #14 was admitted for treatment on May 11, 2018, but the patient's individualized treatment plan was not completed until July 19, 2018.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
HOW:
1.It is the expectation per the OTP/AIR Program's policy that a preliminary treatment plan be completed on the day of admission, a master/comprehensive treatment plan be completed within 30 days of admission, and all treatment plan reviews be completed every at least every 60 days during treatment.
2.Staff reeducated on the policy and procedure during weekly staff meeting.
3.Site manager initiated weekly chart audits for treatment plan compliance.
4.Non-compliance with this mandate will be addressed by the site manager through staff coaching, retraining and disciplinary action.
5.Patient #2 and #8 findings resolved.
WHEN:
1.Site Manager provided training and education to all clinic staff addressing treatment plan procedure and policy procedures and guidelines: March 11, 2019.
2.Site manager initiated weekly chart audits initiated March 12th 2019.
3.Patient # 2: Chart closed. Patient no longer in active treatment.
4.Patient #8: Patient's Comprehensive treatment plan update signed via paper form on 11/15/2018. And scanned into electronic chart on March, 6th, 2019.
5.Patient #8: Patient's Comprehensive treatment plan update signed on 1/21/19
WHO:
1.Site manager and/or Staff Designee appointed by Site Manager will audit charts weekly until compliance is reached for three (3) consecutive months.
2.Program Director will receive the weekly audit results until full compliance is met for three (3) consecutive months.
3.Following three (3) consecutive months of full compliance, the audit results will be reported monthly to the Program Director.
4.Staff deficient in this area will be identified for intensive retraining and performance coaching by the Site Manager overseen by the Program Director.
5.Ongoing results will be reported out quarterly at the Quality Committee of the Board
6.If compliance falls below threshold, the area in need of improvement will be sent to the Performance Improvement Committee for priority attention.
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709.28 (c) 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.
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Observations
The facility failed to obtain the required consent to release information from a patient to release information from the patient's record.
Patient #13 was admitted for treatment on September 10, 2018, and was an active patient at the time of the on-site inspection. There was no valid consent to release information for the patient's funding source, but the facility was billing the funding source for treatment.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
HOW:
1.Reeducate staff
2.Weekly chart audits to ensure compliance
3.Patient # 13 ROI for third Party Payer resolved.
WHEN:
1.Staff Training: Site Manager, Kathleen Hoagland, to provide training and education to all clinic staff addressing 709.28 (c) LICENSURE Confidentiality: (c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. Treatment/rehabilitation management procedure and proposed policy revisions March 7th, 2019.
2.Weekly chart audits initiated March 7th, 2019.
3.Patient # 13 ROI for third Party Payer resolved on 3/26/19. Delay due to patient not engaged in treatment for a period of time.
WHO:
1.Site Manager/Staff Designee will audit charts weekly to ensure for full compliance.
2.Program Director will receive the weekly audit results until compliance is met for 3 consecutive months
3.Once full compliance is reached on a weekly basis for three (3) consecutive months, the Site Manager will continue to audit this regulatory requirement in line with the facility's monthly chart auditing process.
4.Following three (3) months of consecutive compliance, the audit results will be reported monthly by the Site Manager to the Program Director.
5.Staff deficient in this area will be identified for intensive retraining and performance coaching by the Site Manager overseen by the Program Director.
6.Ongoing results will be reported out quarterly at the Quality Committee of the Board
7.If compliance falls below threshold, the area in need of improvement will be sent to the Performance Improvement Committee for priority attention.
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility failed to properly screen two patients prior to the administration of a narcotic agent.
Patient #4 was admitted for treatment on July 10, 2018, and dosed with methadone on July 10, 2018, but the face-to-face determination of physiological dependence and 1 year history of physiological dependence was performed by a certified nurse practitioner and not a narcotic treatment physician.
Patient #5 was admitted for treatment on July 18, 2018, and dosed with methadone on July 18, 2018, but the face-to-face determination of physiological dependence and 1 year history of physiological dependence was performed by a certified nurse practitioner and not a narcotic treatment physician.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
HOW:
1.Process changed to reflect policy that allows ONLY Physicians to conduct a Face-to-face interview for all methadone intakes to verify opioid use disorder.
2.ALL staff trained on this requirement and regulation during clinical staff meeting.
WHEN:
1.Process change that allows ONLY Physicians to conduct a Face-to-face interview for all methadone intakes to verify opioid use disorder completed: January 24, 2019.
2.All staff trained on this requirement and regulation at the staff meeting: January 24, 2019.
WHO:
1.Site Manager or Staff Designee will audit all charts to ensure compliance
2.Program Director will receive audit results on a weekly basis.
3.Non-compliance will be reported by the Site Manager to the Program Director for immediate action.
4.Any non-compliance will be immediately reported to the Medical Executive Committee for corrective action.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
The facility failed to ensure that it conducted monthly drug urinalysis screens for each of its patients.
Patient #4 was admitted for treatment on July 10, 2018, and was an active patient at the time of the on-site inspection, but there was no documented drug urinalysis screen for the month of December 2018.
Patient #5 was admitted for treatment on July 18, 2018, and was an active patient at the time of the on-site inspection, but there was no documented drug urinalysis screen for the month of December 2018.
Patient #6 was admitted for treatment on March 15, 2018, and was discharged on October 4, 2018, but there was no documented drug urinalysis screen for the month of September 2018.
These findings were reviewed with facility staff as part of the on-site inspection.
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Plan of Correction
HOW:
1.Electronic chart documentation templates revised to reflect review of point of care toxicology testing that must occur at the initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
2.Reeducation for ALL staff.
3.Chart audit tool revised to include regulatory compliance that reflects an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
4.Weekly chart audits to ensure compliance with the regulatory requirement.
WHEN:
1. Electronic chart builds and revisions for urinalysis testing that occurs monthly with corresponding stop gaps and alerts that support the process: March 7th, 2019.
2. Staff reeducation/ Training: Site Manager to provide training and education to all clinic staff addressing regulatory requirements: March 7th, 2019.
3. Weekly chart audits initiated March 7th, 2019.
WHO:
1. Program Manager/Staff Designee will audit charts weekly for full compliance.
2. Program Director will receive urinalysis audit reports until compliance is met for 3 consecutive months.
3. Following three (3) months of consecutive compliance, the audit results will be reported monthly to the Program Director.
4. Staff deficient in this area will be identified for intensive retraining and performance coaching by the Site Manager overseen by the Program Director.
5. Ongoing results will be reported out quarterly at the Quality Committee of the Board
6. If compliance falls below threshold, the area in need of improvement will be sent to the Performance Improvement Committee for priority attention.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The facility failed to ensure that all of its patients with less than 2 years of treatment received the required 2.5 hours of psychotherapy per month 1 hour of which shall be individual psychotherapy.
Patient #3 was admitted for treatment on July 6, 2018, and was an active patient at the time of the on-site inspection. There was no documented psychotherapy for the patient for the month of October 2018.
Patient #10 was admitted for treatment on June 22, 2018, and was an active patient at the time of the on-site inspection. There was no documented individual psychotherapy for the patient from August 24, 2018, through November 9, 2019.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
HOW:
1.Staff trained on this new clinical pathway that supports 2.5 hours of psychotherapy per month.
2.TEAM meeting held weekly to review patients out of compliance with 2.5 hours of psychotherapy. Treatment plans revisions completed that support compliance with 2.5 hours per month psychotherapy requirement.
3.New process that treatment HOLDS can only be removed by management.
WHEN:
1.Staff Training conducted March 6th, 2019.
2.TEAM Meeting to review patients out of compliance scheduled weekly starting April 1st, 2019.
WHO:
1. Site Manager will audit charts on a weekly basis until full compliance is met for three consecutive months.
2. Program Director will receive the weekly audit results until full compliance is met for 3 consecutive months.
3. Following three (3) months of consecutive compliance, the audit results will be reported monthly.
4. Staff deficient in this area will be identified for intensive retraining and performance coaching by the Site Manager overseen by the Program Director.
5. Ongoing results will be reported out quarterly at the Quality Committee of the Board
6. If compliance falls below threshold for more than 3 months, the area in need of improvement will be sent to the Performance Improvement Committee for priority attention.
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715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
The facility failed to document that it sent all of the required patient information to the narcotic treatment program that it was transferring a patient to.
Patient #3 was admitted for treatment on March 15, 2018, and transferred to another narcotic treatment program on October 4, 2018, but the facility did not document that it sent the patient's urinalysis reports or summary to the receiving narcotic treatment program.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
HOW:
1.Staff retraining
2.Policy revised that includes that require the narcotic treatment program that transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient. (1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
3.Transfer checklist created and made a part of the intake paperwork process
4.Auditing tool includes Transfer in/out paperwork as a pass/fail checkbox.
WHEN:
1.Policy revisions for the transfer of patients is pending approval ? April 30th, 2019.
2.Transfer checklist that supports policy revision created and presented to staff March 3rd, 2019.
3.Staff Retrained on March 3rd, 2019.
4.Audit element added to the auditing tool March 3rd, 2019
WHO:
1.Site Manager will audit all transfer in/out charts monthly until compliance is met for three consecutive months.
2.Program Director will receive the audit results on all transfer in/out charts until compliance is met.
3.Following three (3) months of consecutive compliance, the review will be added to the monthly audit tool.
4.Staff deficient in this area will be identified for intensive retraining and performance coaching by the Site Manager overseen by the Program Director.
5.Results will be reported out at the Quality Committee of the Board on a quarterly rotation schedule.
6.If compliance falls below threshold for more than 3 months, the area in need of improvement will be sent to the Performance Improvement Committee for priority attention for process improvement.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
The facility failed to ensure that it documented in writting that it notified the transferring narcotic treatment program that the receiving facility had dosed the patient.
Patient #2 was transferred to the facility from another narcotic treatment facility on December 5, 2018, and was dosed at the receiving facility.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
HOW:
1.Staff retraining in the weekly staff meeting.
2.Policy revision ? approval April 30, 2019
3.TRANSFER-IN CHECKLIST FORM created for all intakes that includes the following:
TRANSFER-IN CHECKLIST FORM STATES THE FOLLOWING: The AIR Program staff must document in writing that it notified the transferring NTP program of the admission of the patient and the date of the initial does given to the patient by the receiving NTP.
4.Auditing tool includes full completion of the TRANSFER-IN CHECKLIST FORM to be considered compliant
WHEN:
1.Transfer checklist created and presented to staff March 3rd, 2019.
2. Staff Retrained on March 3rd, 2019.
3. TRANSFER-IN CHECKLIST FORM added to the auditing tool March 3rd, 2019
WHO:
1.Site Manager and/or staff designee will audit all transfer in/out charts monthly until full compliance is met for three consecutive months.
2.Program Director will receive the audit results on all transfer in/out charts until full compliance is met.
3. Following three (3) months of consecutive compliance, the review will be added to the monthly audit tool.
4. Staff deficient in this area will be identified for intensive retraining and performance coaching by the Site Manager overseen by the Program Director.
5. Results will be reported out at the Quality Committee of the Board on a quarterly rotation schedule.
6. If compliance falls below threshold for more than 3 months, the area in need of improvement will be sent to the Performance Improvement Committee.
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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.
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Observations
The facility failed to ensure that treatment plans were updated at least once every 60 days on 3 of 10 applicable patient records reviewed during the on-site inspection.
Patient #10 was admitted for treatment on June 22, 2018, and was an active patient at the time of the inspection. At the time of the on-site inspection the patient's most recent treatment plan update was dated September 24, 2018.
Patient #11 was admitted for treatment on November 13, 2017, and was discharged on August 6, 2018. The last treatment plan update for the patient prior to the patient's discharge was dated May 14, 2018.
Patient #14 was admitted for treatment on May 11, 2018, and was an active patient at the time of the inspection. The patient's individualized treatment plan was dated July 19, 2018, but the patient's treatment plan was not updated until October 17, 2018.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
HOW:
1.Revision of AIR Policy to mandate preliminary treatment plan completed on day of admission, master/comprehensive treatment plan due within 30 days of admission, and treatment plan reviews completed every 60 days during treatment.
2.Staff training on new policy and processes
WHEN:
1.Policy revision approval secured by April 30, 2019.
2.Site Manager to provide training and education to all clinic staff addressing updated treatment plan procedure and proposed policy revisions March 11, 2019.
3.Weekly chart audits initiated March 12th 2019.
WHO:
1.Program Manager/Staff Designee will audit charts weekly until compliance is reached for three (3) consecutive months.
2.Program Director will receive the weekly audit results until compliance is met for 3 consecutive months.
3.Following three (3) months of consecutive compliance, the audit results will be reported monthly to the Program Director.
4.Staff deficient in this area will be identified for intensive retraining and performance coaching by the Site Manager overseen by the Program Director.
5.Ongoing results will be reported out quarterly at the Quality Committee of the Board
6.If compliance falls below threshold for more than 3 months, the area in need of improvement will be sent to the Performance Improvement Committee for priority attention.
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