INITIAL COMMENTS
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This report is a result of an unannounced on-site license provisional and methadone monitoring inspection on August 16, 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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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 two out of four applicable records reviewed.
Patient #5 was admitted on May 15, 2023 and was still active at the time of the inspection. In July 2023, the patient only received 45 minutes of individual therapy.
Patient#10 was admitted on July 26, 2022 and was still active at the time of the inspection. In May and June 2023, the patient did not receive any hours of psychotherapy.
This is a repeat citation from the January 17, 2019, February 27, 2020, March 16, 2021, January 25, 2022 and March 7, 2023 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 counselors on the psychotherapy hour requirements to occur on 9/20/23.
2) Clinical manager and Clinical Supervisor to review counselor caseloads during supervision at the beginning of each month to identify counseling requirements.
3) Counselors responsible to have all patients scheduled for required psychotherapy hours for the month. Will focus on scheduling appointments for 60 minutes (instead of 45 minutes), as well as rescheduling any additional appointments for the month before leaving office/session. Counselors will also 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. Counselors to document if a patient refused to stay for the full-time of a scheduled session.
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.
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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 1 hour per month of psychotherapy during the third and fourth year of treatment in one out of three applicable records.
Patient #8 was admitted on June 14, 2021 and was still active at the time of the inspection. In June 2023, there was no documentation that the patient received any psychotherapy.
This is a repeat citation from the January 25, 2022, and March 7, 2023 licensing inspections.
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 counselors on the psychotherapy hour requirements to occur on 9/20/23.
2) Clinical manager and Clinical Supervisor to review counselor caseloads during supervision at the beginning of each month to identify counseling requirements.
3) Counselors responsible to have all patients scheduled for required psychotherapy hours for the month. Will focus on scheduling appointments for 60 minutes (instead of 45 minutes), as well as rescheduling any additional appointments for the month before leaving office/session. Counselors will also 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. Counselors to document if a patient refused to stay for the full-time of a scheduled session.
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.
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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 with all areas of regulation addressed within the regulatory timeframe in one out eight applicable records reviewed.
Patient #9 was admitted on June 3, 2019 and was still active at the time of the inspection. The annual evaluation was due no later than June 3, 2023; however, it was not completed until June 9, 2023.
This is a repeat citation from the January 25, 2022 and March 7, 2023 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) Re-education and training for all counselors on requirements for completion of annual evaluations to occur on 9/20/23.
2) Clinical manager to send monthly list of patients with upcoming anniversary dates one month prior, to identify patients in need of annual evaluation update the following month and to ensure completion of annual evaluation is done timely.
3) Counselors expected to document annual evaluations for caseload prior to patient admission anniversary.
4) Clinical Manager responsible to monitor compliance weekly via chart review and will send additional weekly reminders as needed.
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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, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for providing the required 2.5 hours of psychotherapy during the patient ' s first two years was approved by the Department for the January 17, 2019, February 27, 2020, March 16, 2021, January 25, 2022, and March 7, 2023, licensing inspections. Not providing 2.5 hours of psychotherapy was again found to be a deficiency in the August 16, 2023 licensing inspection.
A plan of correction for providing the required 1 hour of psychotherapy per month for patients in their third and fourth year was approved by the Department for the January 25, 2022, and March 7, 2023, licensing inspections. Not providing 1 hour of psychotherapy was again found to be a deficiency in the August 16, 2023 licensing inspection.
A plan of correction for documenting annual evaluations of the patient ' s status within the regulatory time frame was approved by the Department for the January 25, 2022, and March 7, 2023, licensing inspections. Competing annual evaluations of the patient ' s status within the regulatory time frame was again found to be a deficiency in the August 16, 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 to monitor compliance with listed citations.
2. Monthly Chart audit results will be sent to the PPI Health Information and Process Management Committee for review.
3. Any identified weaknesses or audit concerns will be addressed within that month for corrective action and resolution.
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