INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 29, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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
Based on a review of personnel records and the facility-submitted Staffing Requirement Facility Summary Report, the facility failed to ensure that all staff completed at least 4 hours of TB/STD and other health-related topics training and a minimum of 6 hours of HIV/AIDs training within the regulatory timeframe in one of three applicable personnel records reviewed.
Employee #4 was hired as a counselor on November 9, 2020. The TB/STD training was to be completed no later than November 9, 2021; however, there was documentation in the record that only three of the four required hours were completed at the time of the inspection. The HIV/AIDs training was to be completed no later than November 9, 2021; however, there was documentation in the record that only three of the six required hours were completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
Citation #: L 0067
Date to be Completed By: 11/11/22
Responsible Party: Facility and Program Director ("Director") for Behavior Health
Action:
I. Program Director reviewed 704.11(c)(1) 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. Completed 9/03/2022. The review revealed an opportunity to re-educate unit staff on the procedures outlined in the policy and improve the ongoing process of ensuring completion per standard, as well as auditing procedures to ensure adherence to training standards and expectations.
II. Staff were re-educated expectations surrounding
annual training completion.
III. All staff will sign off on annual training plan and individual training plan to ensure they understand requirements of role by 10/31/22.
IV. All staff will provide their direct supervisor with plan for scheduled required courses for annual training for fiscal training year (Jan 1 ? Dec 31) by
10/31/22. New staff must provider their direct supervisor with plan for scheduled courses as part of the onboarding orientation checklist to confirm training will be completed per standard. Training will be confirmed at their 6-month initial evaluation, and ongoing at their annual evaluation until compliance is met and they are signed off as meeting their required training requirements.
V. Supervisors will audit staff files monthly to ensure they are meeting educational requirements for role and DDAP requirement. For the next year the Director of the program will submit a review to indicate these requirements are met for applicable staff when reporting to the Clinical Effectiveness and Quality Assurance Committee for ongoing quality assurance and performance improvement (QAPI).
VI. Employee record #4 as cited in survey has been scheduled to complete the remaining one of the required four hours of TB/STD training as well as the remaining three of the six required hours for HIV/AIDs training. HIV training is scheduled 10/6/22 & 10/7/22 and TB Training is scheduled for 11/11/22.
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711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance 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 specific information to be disclosed is included on all informed and voluntary consent to release information forms were submitted and approved for the September 30, 2021 and April 1, 2021 annual licensing inspections. Ensuring the specific information to be disclosed is included on all informed and voluntary consent to release information forms was again found to be a deficiency in the August 29, 2022 licensing inspection.
Additionally, plans of correction for ensuring that treatment and rehabilitation plans are reviewed and updated every 60 days were submitted and approved by the Department for the September 30, 2021 and April 1, 2021 annual licensing inspections. Ensuring that treatment and rehabilitation plans are reviewed and updated every 60 days was again found to be a deficiency in the August 29, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Citation #: A A042
Date to be Completed By: 10/31/22
Responsible Party: Facility and Program Director ("Director") for Behavior Health
Action:
I. Program Director reviewed 711.17(a)(3) Subchapter B. Approval Procedures and previously submitted correction and improvement plans. Review of previous plans and adherence to plans revealed opportunities to improve adherence through increased and ongoing internal review and oversight by Director or designee in order to meet the previously outlined plans to meet performance improvement objectives.
II. Director assigned counselors chart auditing responsibilities to review at least 30 charts within the past 30 days to ensure adherence to standard for all of their assigned patients for both consents and treatment plans. These will be reviewed in weekly individual supervision with counselor and supervisor. This will be maintained until six months of sustained compliance at 100% is achieved.
III. Self-auditing of charts by counselors will be outlined as an expectation of counselor's role and responsibilities which counselors will sign-off on understanding for to be completed by 10/31/22.
IV. Director or designee will perform chart audits of at least 30 charts/month to ensure compliance in adherence to documentation and record keeping standards. This will be maintained until six months of sustained compliance at 100% is achieved.
V. Director or designee of the Program Director will report results to the PPMC Clinical Effectiveness and Quality Improvement (CEQI) Committee as part of PPMC's ongoing quality assurance and performance improvement activities. The Committee will evaluate the results and implement any further process changes and audits, as needed. This will be maintained until six months of sustained compliance at 100% is achieved.
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711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in two of three applicable client records reviewed.
Client #2 was admitted on March 15, 2022 and was active at the time of inspection. A treatment plan update was completed on June 16, 2022 and the next update was due no later than August 16, 2022; however, the update was not completed until August 25, 2022.
Client #3 admitted on April 4, 2022 and was active at the time of inspection. A comprehensive treatment plan was completed on May 6, 2022 and the next update was due no later than July 6, 2022; however, the update was not completed until July 15, 2022.
This is a repeat citation from the April 1, 2021 and September 30, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Citation #: L 0969
Date to be Completed By: 10/31/22
Responsible Party: Facility and Program Director ("Director") for Behavior Health
Action:
I. Program Director reviewed 711.92(d) Tx Plan Update, 711.92. Treatment and rehabilitation services. (d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days; Policy 22.05 Treatment Plan Updates and the associated improvement plans from previous years' reviews. Completed 9/03/2022. The review revealed an opportunity to improve and enhance improvement plans and reeducate staff on the procedures outlined in the plans to meet performance improvement objectives.
II. Program Director reeducated program staff on Policy 22.05 Treatment Plan Updates by rounding with staff on 8/24/2022. Proper completion of treatment plans including initial treatment plan completion within 7 days of intake, master treatment plan completion within 30 days of intake and follow-up treatment plans for ASAM 1.0 outpatient level of care every 60 days after completion of master treatment plan and ASAM 2.1 intensive outpatient treatment every 30 days after completion of master treatment plan.
III. Program Director assigned counselors
routine chart auditing responsibilities to
ensure adherence to standard during the
review period for all of their assigned
patients.
IV. Self-auditing of charts by counselors will be outlined as an expectation of counselor's role and responsibilities which counselors will sign-off on understanding for to be completed
by 10/31/22.
V. Counselors will review 30 charts/month. If there is less than 30 patients, then the total census of patients/month on unit, will be audited for Treatment Plan compliance
according to level of care until six months of sustained compliance at 100% is achieved.
VI. Program Director or designee will perform chart audits to ensure compliance of counselor's adherence to their chart audit responsibilities.
VII. Program Director or designee of the
Program Director will report results to the PPMC Clinical Effectiveness and Quality Improvement (CEQI) Committee as part of the Facility's quality assurance and performance improvement activities. The Committee will evaluate the results and implement any further process changes and audits, as needed.
Clients
VIII. Client #2 and Client # 3 records noted in findings are were still active patients at the time of the finding, however the due dates for the treatment plan updates have passed and cannot be updated to be in compliance with Policy 22.05 Treatment Plan Updates however, the primary counselors will be reeducated for future documentation compliance. Completion of the training will be documented in the unit's staff training record. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) 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 four applicable client records reviewed.
Client #4 was admitted on October 7, 2021 and was discharged on November 12, 2021.
Client #5 was admitted on September 3, 2021 and was discharged on October 25, 2021.
Client #6 was admitted on June 10, 2021 and discharged on November 22, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Citation #: L 0989
Date to be Completed By: 10/31/22
Responsible Party: Facility and Program Director ("Director") for Behavior Health
Action:
I. Program Director reviewed 711.93(a)(7) Follow-up Information, 711.93. Client records. (a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following: (7) Follow-up information and the associated program policy 35.02 Post-Discharge Follow-Up Contacts.
Completed 9/03/2022. The review revealed an opportunity to re-educate unit staff on the procedures outlined in the policy.
II. Program Director reeducated program staff on policy 35.02 Post-Discharge Follow-Up Contacts including where documentation is entered in the patient's electronic medical record (EMR) by rounding with teams on all shifts. Reeducation of Clinical Staff will be completed by 10/31/2022.
III. Records noted in findings are discharged patients and cannot be updated however the primary counselors will be reeducated on the requirements for documentation. Completion of the training will be documented in the unit's staff training record.
IV. Program Director assigned counselors routine chart auditing responsibilities to ensure adherence to standards during the review period for all of their assigned patients.
Counselors will review 30 charts/month.
If there is less than 30 patients, then the total census of patients/month on unit, will be audited for follow-up documentation according to level of care until six months of sustained compliance at 100% is achieved.
V. Program Director or designee of the Program Director will report results to the PPMC Clinical Effectiveness and Quality Improvement (CEQI) Committee as part of the PPMC ongoing quality assurance and performance improvement activities. The Committee will evaluate the results and implement any further process changes and audits, as needed.
VI. Client #4 was discharged on November 12, 2021; Client #5 discharged on October 25, 2021. Client #6 was discharged on November 22, 2021 surpassing follow-up within 1 month of discharge and as such records could not be updated to be in compliance with policy 35.02 Post-Discharge Follow-Up Contacts the primary counselors will be reeducated on the requirements for documentation. Completion of the training will be documented in the unit's staff training record. |
711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(ii) The specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent forms in two of seven client records reviewed.
Client #3 was admitted on April 4, 2022 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on April 4, 2022; however, the form did not include the specific information to be disclosed.
Client #4 was admitted on October 7, 2021 and was discharged on November 12, 2021. A release of information form to the funding source was signed and dated by the client on October 7, 2021; however, the form did not include the specific information to be disclosed.
This is a repeat citation from the April 1, 2021 and September 30, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Citation #: L 1003
Date to be Completed By: 10/31/22
Responsible Party: Facility and Program Director ("Director") for Behavior Health
Action:
I. Program Director reviewed 711.93(c)(2)(ii) Specific Info. Disclosed (Consents)
711.93. Client records. (c) Confidentiality; Policy 10.103 Confidentiality for Psychiatric and Substance Use Disorders, and the corresponding Consent to Release of Information form. Completed 9/03/2022. The review revealed an opportunity to re-educate unit staff on the procedures outlined in the policy.
II. Program Director reviewed Policy 10.103 Confidentiality for Psychiatric and Substance Use Disorders, and the corresponding Consent to Release of Information form. Completed 9/03/2022. The Director also confirmed the corresponding Consent to Release information form is available, so that only this new updated and approved form is used. Completed 9/03/2022.
III. Program Director will reeducate unit staff on policy 10.103, Consent to Release Information, and completing the Consent to Release Information form by rounding with teams on all shifts. Reeducation of Clinical Staff will be completed by 10/31/2022 and documented
IV. Records noted in findings are discharged patients and cannot be updated however the primary counselors will be reeducated on requirements for documentation compliance. Completion of the training will be documented in the unit's staff training record.
Program Director assigned counselors ongoing open chart auditing responsibilities to verify adherence to standard during the review period for all of their assigned patients. Self-auditing of charts by counselors will be outlined as an expectation of counselor's role and responsibilities and counselors will sign-off on their understanding. To be completed by 10/31/22.
30 charts/month or total census of patients/month on unit if less than 30 patients, will be audited for Consent to Release Information form compliance until six months of sustained compliance at 100% is achieved.
Program Director or designee will also perform chart audits, to verify compliance of counselor's adherence to chart audit responsibilities.
V. Program Director or designee will report results to the Penn Presbyterian Medical Center (PPMC) Clinical Effectiveness and Quality Improvement (CEQI) Committee as part of PPMC's ongoing quality assurance and performance improvement (QAPI) activities. The CEQI Committee will evaluate the results and implement any further process changes and audits, as needed.
VI. Clients Listed in the Findings:
Client #3 was admitted on April 4, 2022 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on April 4, 2022; however, the form did not include the specific information to be disclosed. The form was updated with patient to include the reason for release of information to funding source.
Client #4 was admitted on October 7, 2021 and was discharged on November 12, 2021. A release of information form to the funding source was signed and dated by the client on October 7, 2021; however, the form did not include the specific information to be disclosed.
No updates could be made to these encounters/patients' files to reflect changes specified in corrective action plan for charts to be in compliance with § 710.23. Patient records. 4 Pa. Code § 255.4 and § 255.5 (relating to UDCS: confidentiality and access to information and projects; and coordinating bodies: disclosure of client-oriented information) however the counselors will be re-educated on the requirements for documentation. Completion of the training will be documented in the unit's staff training record. |