INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on March 6 & 7, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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705.28 (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
Based on a review of fire drill logs from February 2022-January 2023, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring in April 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Fire Drills will be scheduled monthly at the start of the year.
2. PPI Safety Officer responsible for ensuring that fire drills are scheduled and coordinated with PPI Security and local fire department.
3. PPI Safety Officer responsible for follow-up on the day of scheduled fire drill to confirm that drill occurred and all documentation is complete.
4. PPI Safety Officer responsible to reschedule any fire drills that were incomplete or did not occur as expected, by the end of the current month.
5. Fire drill documentation and compliance will be monitored monthly by the PPI Safety Office and PPI Director of Compliance.
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of ten client records, the facility failed to notify one applicable client, in writing, that the client has the opportunity to request reconsideration of a decision terminating treatment.
Client #7 was admitted on December 28, 2022 and was discharged on July 26, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Re-education and training to all clinical staff on termination policy and corresponding documentation occurred on 4/12/23.
2. All administrative terminations to be reviewed by Clinical Manager prior to decision being issued to patient, to monitor and ensure that policy is followed and is in compliance with regulation.
3. Clinical Manager responsible to ensure plan of correction is implemented.
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients.
During the week of November 21-27, 2022, the patient census was 282. The facility was required to provide at least 28.2 physician hours. There were only 20 physician hours documented.
During the week of December 26, 2022 and January 1, 2023, the patient census was 277. The facility was required to provide at least 27.7 physician hours. There were only 12 physician hours documented.
During the week of January 16-22, 2023, the patient census was 277. The facility was required to provide at least 27.7 physician hours. There were only 20 physician hours documented.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Physician schedules will be monitored by the Medical Director and Office Coordinator, to ensure there is enough onsite physician coverage for current census.
2. Any physician callouts or planned time off will be monitored by the Medical Director and Office Coordinator, and additional physician coverage will be set up and confirmed to cover those hours, to ensure enough onsite physician coverage.
3. This finding was a reporting error, but not a coverage error, as physicians are on site for longer than they are seeing patients. Moving forward, we will report all physician hours, including nonclinical, that they are available on site for patient emergencies and care. In addition, as the OTP is embedded within an acute psychiatric hospital, there is plenty of on site physician coverage in the event of time off for physicians at the OTP. We will be reporting this as well moving forward.
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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
Based on a review of patient records, the facility failed to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in one out of four applicable records reviewed.
Patient #1 was admitted on August 2, 2022 and was still active at the time of the inspection. In November and December 2022, the patient did not receive any individual or group psychotherapy sessions. In January 2022, the patient received only 1.5 hours of individual psychotherapy.
This is a repeat citation from the January 17, 2019, February 27, 2020, March 16, 2021, and January 25, 2022 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1) Re-education and training to all clinical staff on required psychotherapy hours based on time in treatment occurred on 4/12/23.
2) Clinical manager and Clinical Supervisor to review counselor caseloads during supervision at the beginning of each month.
3) Counselors responsible to have all patients scheduled for required psychotherapy hours for the month.
4) Counselors will utilize stop dose holds, phone calls, outreach efforts, etc. to encourage patient compliance and attendance.
5) Counselors to document all correspondence/ contacts with patient, including outreach attempts, rescheduled appointments, cancellations and no-show documentation if patient did not attend the scheduled sessions.
6) Clinical Manager and Clinical Supervisor responsible to monitor compliance monthly with counselors. Monitoring to be completed via monthly chart audits and caseload review during supervision.
7) Clinical Manager responsible to ensure plan of correction is implemented.
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715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide patients with one hour per month of therapy during the third and fourth year of treatment in two out of three applicable records.
Patient #3 was admitted on June 1, 2020 and discharged on October 18, 2022. In July and August of 2022, there was no documentation that the patient received any individual or group therapy.
Patient #8 was admitted on June 1, 2020 and discharged on October 18, 2022. In July and August, there was no documentation that the patient received any individual or group therapy.
This is a repeat citation from the January 25, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) Re-education and training to all clinical staff on required psychotherapy hours based on time in treatment occurred on 4/12/23.
2) Clinical manager and Clinical Supervisor to review counselor caseloads during supervision at the beginning of each month.
3) Counselors responsible to have all patients scheduled for required psychotherapy hours for the month.
4) Counselors will utilize stop dose holds, phone calls, outreach efforts, etc. to encourage patient compliance and attendance.
5) Counselors to document all correspondence/ contacts with patient, including outreach attempts, rescheduled appointments, cancellations and no-show documentation if patient did not attend the scheduled sessions.
6) Clinical Manager and Clinical Supervisor responsible to monitor compliance monthly with counselors. Monitoring to be completed via monthly chart audits and caseload review during supervision.
7) Clinical Manager responsible to ensure plan of correction is implemented.
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715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide patients with one hour of psychotherapy every two months after the fourth year of treatment in one out of three applicable records reviewed.
Patient #10 was admitted on February 21, 2018 and was still active at the time of the inspection. In November and December of 2022, there was no documentation that the patient received individual or group therapy.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1) Re-education and training to all clinical staff on required psychotherapy hours based on time in treatment occurred on 4/12/23.
2) Clinical manager and Clinical Supervisor to review counselor caseloads during supervision at the beginning of each month, to identify patient counselor hour requirements for that month.
3) Counselors responsible to have all patients scheduled for required psychotherapy hours for the month.
4) Counselors will utilize stop dose holds, phone calls, outreach efforts, etc. to encourage patient compliance and attendance.
5) Counselors to document all correspondence/ contacts with patient, including outreach attempts, rescheduled appointments, cancellations and no-show documentation if patient did not attend the scheduled sessions.
6) Clinical Manager and Clinical Supervisor responsible to monitor compliance monthly with counselors. Monitoring to be completed via monthly chart audits and caseload review during supervision.
7) Clinical Manager responsible to ensure plan of correction is implemented.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to document an annual physical examination given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician in five out of seven applicable records reviewed.
Patient #4 was admitted on July 17, 2018 and was still active at the time of the inspection. An annual physical was due no later than July 17, 2021; however, there was no documentation in the patient ' s record of it being completed.
Patient #6 was admitted on February 7, 2020 and discharged on October 6, 2022. An annual physical was due no later than February 7, 2022; however, there was no documentation in the patient's record of it being completed.
Patient #7 was admitted on December 28, 2018 and discharged on July 26, 2022. An annual physical was due no later than December 28, 2021; however, there was no documentation in the patient's record of it being completed.
Patient #8 was admitted on June 1, 2020 and discharged on October 18, 2022. An annual physical was due no later than June 1, 2022; however, there was no documentation in the patient's record of it being completed.
Patient #10 was admitted on February 21, 2018 and was still active at the time of the inspection. An annual physical was due no later than February 21, 2022; however, it was completed on October 21, 2022.
This is a repeat citation from the January 25, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) Patient #4, resolved with annual physical scheduled for 4/24/23.
2) Patient #10, resolved with annual physical occurred 3/17/23.
3) New computer-generated reports have been designed through the collaboration of the Clinical Manager, the Nurse Manager, and the Informatics department, to include alerts two-months ahead of each patient's anniversary date.
4) This report will be monitored monthly by the Nurse Manager and annual physical appointments will be scheduled a month ahead of due date.
5) No show appointments will be logged by nursing staff daily. At the end of the week, stop dose holds will be placed on patients who need to reschedule an appointment. Front desk staff will be responsible to reschedule appointments for patients with stop dose holds, when they arrive for next dosing day.
6) The annual physical note template has been redesigned to capture annual re-evaluation, which will take place at the annual visit.
7) Re-education of medical and nursing staff on requirements of documentation to be completed by the medical director and the nursing manager by 4/28/23.
8) Monthly compliance auditing will be done by the nurse manager at the end of each month.
9) Stop dose holds will also be used after two no show appointments, to discuss their attendance. Patients will meet with nursing or medical staff to receive education about the necessity of the annual physical examination, in order to monitor current health status and current plan of treatment.
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715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
Based on the review of the facility ' s policy and procedures manual and patient records, the facility failed to document at least one case consultation a year in four out of eight applicable patient records reviewed.
Patient #3 was admitted on April 16, 2019 and was still active at the time of the inspection. There was one no documentation that a case consultation occurred in the year of 2022.
Patient #7 was admitted on admitted on December 28, 2018 and discharged on July 26, 2022. There was one no documentation that a case consultation occurred in the year of 2022.
Patient #8 was admitted on June 1, 2020 and discharged on October 18, 2022. There was one no documentation that a case consultation occurred in the year of 2022.
Patient #10 was admitted on February 21, 2018 and still active at the time of the inspection. There was one no documentation that a case consultation occurred in the year of 2022.
This is a repeat citation from the January 25, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) Patient #3 case consultation completed on 4/13/23 for year of 2023.
2) Patient #10 case consultation complete on 3/17/23 for year of 2023.
3) Other patient charts cited are since discharged and/or the year due has passed.
4) Re-education and training to all clinical staff on frequency and need for Case Consultation notes occurred on 4/12/23.
5) Counselors expected to document case consultation for any patients discussed during multi-disciplinary team (MDT) meetings and Clinical Supervision meetings.
6) Patients nearing their admission anniversary that have yet to have a case consultation documented, counselors will be expected to discuss the patient case in MDT or Clinical Supervision and document via Case Consultation note.
7) Clinical Manager and Clinical Supervisor responsible to monitor compliance monthly with counselors. Monitoring to be completed via monthly chart audits and caseload review during supervision.
8) Clinical Manager responsible to ensure plan of correction is implemented.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document an annual evaluation of each patient 's status completed by the patient 's counselor and reviewed, dated and signed by the medical director in seven out seven applicable records reviewed.
Patient #3 was admitted on April 16, 2019 and was still active at the time of the inspection. The annual evaluation was due no later than April 16, 2022; however, there was no documentation one was completed.
Patient #4 was admitted on July 17, 2018 and was still active at the time of the inspection. The annual evaluation was due no later than July 17, 2022; however, there was no documentation one was completed.
Patient #6 was admitted on February 7, 2020 and discharged on October 6, 2022. The annual evaluation was due no later than February 7, 2022; however, there was no documentation that one was completed.
Patient #7 was admitted on December 28, 2018 and discharged on July 26, 2022. The annual evaluation was due no later than December 28, 2021; however, was not completed until February 2, 2022.
Patient #8 was admitted on June 1, 2020 and discharged on October 18, 2022. The annual evaluation was due no later than on June 1, 2022; however, there was no documentation that one was completed.
Patient #9 was admitted on August 11, 2020 and was still active at the time of the inspection. The annual evaluation was due no later than August 11, 2022; however, it was not completed until December 12, 2022.
Patient #10 was admitted on February 21, 2018 and was still active at the time of the inspection. The annual evaluation was due no later than February 21, 2023; however, it was not completed until February 28, 2023.
This is a repeat citation from the March 16, 2021 and January 25, 2022 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) Patient #3 annual evaluation complete on 4/13/23 for year of 2023.
2) Other patient charts cited are since discharged and/or the year due has passed.
3) Re-education and training for all clinical staff on requirements for completion of annual evaluations occurred on 4/12/23.
4) Clinical manager and Clinical Supervisor to review counselor caseloads during supervision at the beginning of each month, to identify patients that are nearing their admission anniversary, to ensure completion of annual evaluation is done timely.
5) Counselors expected to document annual evaluations for caseload prior to patient admission anniversary.
6) Clinical Manager and Clinical Supervisor responsible to monitor compliance monthly with counselors. Monitoring to be completed via monthly chart audits and caseload review during supervision.
7) Clinical Manager responsible to ensure plan of correction is implemented.
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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
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in eight out of nine applicable records reviewed.
Client #1 was admitted on August 2, 2022 and was still active at the time of the inspection. A treatment plan was completed on October 7, 2022, and the next update was due no later than December 7, 2022; however, the next update was not completed until January 23, 2023.
Client #3 was admitted on April 16, 2019 and was still active at the time of the inspection. A treatment plan update was completed on March 1, 2022, and the next update was due no later than May 1, 2022; however, it was not completed until August 15, 2022. The next update was due no later than October 15, 2022: however, there is no documentation that one was completed.
Client #4 was admitted on July 17, 2018 and was still active at the time of the inspection. A treatment plan update was completed on January 25, 2022, and the next update was due no later than March 25, 2022; however, there is no documentation that one was completed.
Client #5 was admitted on November 10, 2022 and was still active at the time of the inspection. A treatment plan was completed on November 16, 2022, and the next update was due no later than January 16, 2023; however, it was not completed until January 30, 2023.
Client #6 was admitted on February 7, 2020 and was discharged on October 6, 2022. A treatment plan was completed on May 24, 2022, and the next update was due no later than July 24, 2022; however, it was not completed until September 14, 2022.
Client #7 was admitted on December 28, 2018 and was discharged on July 26, 2022. A treatment plan was completed on June 22, 2021, and the next update was due no later than August 22, 2021; however, there is no documentation that one was completed.
Client #8 was admitted on June 1, 2020 and was discharged on October 18, 2022. A treatment plan was completed on June 10, 2022, and the next update was due no later than August 10, 2022; however, it was not completed until September 23, 2022.
Client #10 was admitted on February 21, 2018 and was still active at the time of the inspection. A treatment plan was completed on June 6, 2022, and the next update was due no later than August 6, 2022; however, it was not completed until September 26, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) Client #1 tx plan most recently updated on 4/12/23.
2) Client #3 tx plan most recently updated on 4/13/23.
3) Client #4 tx plan most recently updated on 3/22/23.
4) Client #5 tx plan most recently updated on 3/31/23.
5) Client #10 tx plan most recently updated on 4/13/23.
6) Other patient charts cited are since discharged.
7) Re-education and training for all clinical staff on treatment plan policy and regulations pertaining to treatment plan updates occurred on 4/12/23.
8) Clinical manager and Clinical Supervisor to review counselor caseloads during supervision at the beginning of each month, to identify patients in need of treatment plan updates that month.
9) Counselors expected to complete treatment plan updates within the 60 days.
10) If patient is not present when treatment plan update is due to be completed, due to lack of attendance or other barriers, counselor is still responsible to complete update to their best of their ability and document that patient was not present for treatment plan update.
11) Clinical Manager and Clinical Supervisor responsible to monitor compliance monthly with counselors. Monitoring to be completed via monthly chart audits and caseload review during supervision.
12) Clinical Manager responsible to ensure plan of correction is implemented.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in four out of ten applicable records reviewed.
Client #3 was admitted on April 16. 2019 and was still active at the time of the inspection. The treatment plan dated August 15, 2022, indicated one hour of individual therapy per week. There was no documentation that the client received one hour of individual therapy weekly in November and December 2022 or January and February 2023.
Client #4 was admitted on July 17, 2018 and was still active at the time of the inspection. The treatment plan dated January 25, 2022, indicated bi-weekly to monthly individual therapy. There was no documentation that the client received any individual therapy in the months of September, October, November, or December of 2022.
Client #8 was admitted on June 1, 2020 and was discharged on October 18, 2022. The treatment plan dated June 10, 2022, indicated two and half hours of therapy a month. There was no documentation that the client received any individual therapy in the months of August and September 2022.
Client #10 was admitted on February 21, 2018 and was still active at the time of the inspection. The treatment plan dated September 26, 2022, indicated bi-weekly individual therapy. There was no documentation that the client received any individual therapy in the months of November and December of 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) Re-education and training to all clinical staff on individualized treatment plan matching appropriate counseling requirements based on time in treatment, occurred on 4/12/23.
2) Counselors responsible to have all patients scheduled for psychotherapy hours, as identified in the treatment plan, for the month.
3) Counselors will utilize stop dose holds, phone calls, outreach efforts, etc. to encourage patient compliance and attendance.
4) Counselors to document all correspondence/ contacts with patient, including outreach attempts, rescheduled appointments, cancellations and no-show documentation if patient did not attend the scheduled sessions.
5) Clinical Manager and Clinical Supervisor responsible to monitor compliance monthly with counselors. Monitoring to be completed via monthly chart audits and caseload review during supervision.
6) Clinical Manager responsible to ensure plan of correction is implemented.
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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 patient records and the facility ' s policy and procedure manual, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for providing patients with 2.5 hours of psychotherapy per month during the patient ' s first two years of treatment was submitted and approved by the Department for the January 25, 2022, March 16, 2021, February 27, 2020, and January 17, 2019, licensing inspections. Failing to provide patients with 2.5 hours of psychotherapy per month during the patient ' s first two years of treatment was again found to be a deficiency in the March 6 & 7 2023 licensing inspection.
A plan of correction for providing patients with at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment was submitted and approved by the Department for the January 25, 2022, licensing inspection. Failing to provide at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment was again found to be a deficiency in the March 6 & 7 2023 licensing inspection.
A plan of correction for completing annual physical examinations by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician was submitted and approved by the Department for the January 25, 2022, licensing inspection. Failing to complete annual physical examinations was again found to be a deficiency in the March 6 & 7 2023 licensing inspection.
A plan of correction for completing case consultation notes regarding the patient was submitted and approved by the Department for the January 25, 2022, licensing inspection. Failing to complete case consultation notes was again found to be a deficiency in the March 6 & 7 2023 licensing inspection.
A plan of correction for completing annual evaluations by the counselor was submitted and approved by the Department for the January 25, 2022, and March 16, 2021, licensing inspections. Failing to complete annual evaluations was again found to be a deficiency in the March 6 & 7 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Monthly chart audits will be completed by the Clinical Manager, Nurse Manager, Clinical Supervisor and Office Coordinate to monitor compliance with licensure regulations and to ensure that plans of correction are being followed.
2. Monthly Chart audit results will be sent to the PPI Health Information and Process Management Committee for review and oversight.
3. Any identified weaknesses or audit concerns will be addressed within that month for corrective action and resolution.
4. Monthly audit results are monitored by the Chairperson of the PPI Health Information and Process Management Committee, and PPI's Chief Nursing Officer.
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