INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 4 & 5, 2025 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) (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
Based on a review of the May through December 2024 fire drill logs during the inspection, the facility failed to document the exit route used on fire drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Re-training for all Safety staff involved in clinic operations regarding regulation requirements for Fire Drill documentation. Re-training to be completed by 2/28/25.
2. Fire Drill documentation form revised to include all areas of regulation requirements, and the correct form will be used going forward as of February 2025.
3. Monitoring of compliance for fire drill documentation will be done by Safety Officer monthly.
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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in two out of eight records reviewed.
Client #1 was admitted on November 27, 2024 and discharged on January 28, 2025. The record contained one informed and voluntary consent to release information to a mental health provider signed by the client on December 9, 2024, that did not include the purpose of disclosure.
Client #8 was admitted on June 20, 2024 and discharged on December 2, 2024. The record contained an informed and voluntary consent to release information to a family member signed by the client on October 3, 2024, that did not include the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Re-training for all staff on how to complete consents to be done,
and hand-outs for future reference to be provided. Re-training of all staff to be completed by 2/28/25.
2. Monitoring of compliance with consent completion to be done with random monthly chart audits by Clinical Manager.
3. **Inquire about ability with EHR system to change format of ROIs to stop ability to sign without all parts checked off.
4. Unable to resolve findings or correct consents due to Client #1 and Client #8 both being discharged at time of findings.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in two of eight client records reviewed.
Client #3 was admitted on November 19, 2024 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for an emergency contact dated November 21, 2024 was offered to the client.
Client #8 was admitted on June 20, 2024 and discharged on December 2, 2024. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source and laboratory dated June 20, 2024 was offered to the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Re-training for all staff on how to complete consents to be done,
and hand-outs for future reference to be provided. Re-training of all staff to be completed by 2/28/25.
2. Monitoring of compliance with consent completion to be done with random monthly chart audits by Clinical Manager.
3. Inquired about ability with EHR system to change format of ROIs to stop ability to sign without all parts checked off. This is possible with system upgrade, and should be implemented by 6/30/2025.
4. Will resolve and correct consent for Client #3 at next scheduled visit, as patient did not attend appt on 2/24/25.
5. Unable to resolve findings or correct consent for Client #8 due to being discharged at time of findings.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed written consent prior to administering an agent in one out of five applicable records.
Patient #4 was admitted on June 3, 2024 and discharged on October 23, 2024. There was no documentation in the patient record that an informed written consent was obtained prior to administering an agent.
This is a repeat citation from December 4 & 5, 2023 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Re-training for all staff on how to complete consents to be done, and hand-outs for future reference to be provided. Re-training of all staff to be completed by 2/28/25.
2. Re-training for all nursing and medical staff regarding process when patient switches forms of MAT, to ensure that all new paperwork required for change in MAT is completed at time of visit. Re-training of all nursing and medical staff to be completed by 2/28/25.
3. Monitoring of compliance with consent completion to be done with monthly chart audits by Clinical Manager. All new patient charts and patient charts that have changed MAT type during that month will be reviewed.
4. Unable to resolve findings or correct consent due to Patient #4 being discharged at time of findings.
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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 by the narcotic treatment physician within the regulatory timeframe in one out of two applicable records reviewed.
Patient #5 was admitted on February 25, 2021 and discharged on March 25, 2024. An annual physical was due no later than February 25, 2024; however, there was no documentation that one was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Re-training for all staff on the regulatory requirements of annual physicals. Re-training of all staff to be completed by 2/28/25.
2. Clinical Manager to send monthly list of annual physicals due prior to start of the month, to alert staff of those needing completion.
3. Counselor will be responsible for outreach and/or alert to be placed on patients whom are to be scheduled for annual physical that month.
4. Nursing team staff will be responsible to document all no-shows for annual medical visits in the patient chart, and provide daily no-show list to Lead RN.
5. Lead RN responsible to place alerts on patients who no-show, in order for them to be rescheduled in a timely manner.
6. Clinical Manager will notify patients of annual physical requirements, and options provided to them (complete at our program with medical visit, or provide copy of own annual physical done elsewhere).
7. Monitoring of compliance with annual physical completed to be done by Clinical Manager monthly. Will review all charts whom are due for that month.
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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 a review of patient records, the facility failed to document an annual clinical evaluation within the regulatory timeframe in one out of two applicable records.
Patient #5 was admitted on February 25, 2021 and discharged on March 25, 2024. The annual clinical evaluation was due no later than on February 25, 2024; however, there is no documentation that one was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Re-training for all clinical staff on the requirements of annual evaluation documentation. Re-training of all clinical staff
to be completed by 2/28/25.
2. Clinical Manager to send monthly list of annual evaluations due prior to start of the month, to alert clinical staff of those needing completion.
3. Monitoring of compliance with annual evaluation documentation to be done by Clinical Manager monthly. Will review all charts whom are due for that month.
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709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations within the policy timeframe in one out of two applicable client records. The facility's policy and procedures manual states that case consults occur annually.
Client #5 was admitted on February 25, 2021 and discharged on March 25, 2024. A case consultation was due no later than February 25, 2024; however, there is no documentation that one occurred.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Re-training for all clinical staff on the requirements of annual case consultation notes. Re-training of all clinical staff
to be completed by 2/28/25.
2. Clinical Manager to send monthly list of case consultations due prior to start of the month, to alert clinical staff of those needing completion.
3. Monitoring of compliance with case consultation notes to be done by Clinical Manager monthly. Will review all charts whom are due for that month.
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