INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 27, 2024, 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:
|
Plan of Correction
|
711.92(a)(3) LICENSURE Mngt of Treatment Services
711.92. Treatment and rehabilitation services.
(a) The project 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 development, approval and ongoing management of treatment/rehabilitation services for clients.
|
Observations
Based on a review of the facility's policy and procedure manual and a discussion with the Facility Director, the facility was not following their guidelines for discharging clients with a pattern of program non-attendance. The policy and procedure manual stated, "If an individual has two consecutive unexcused absences from scheduled sessions or if they present a chronic pattern of missing sessions periodically (e.g. missing one out of every three scheduled appointments), then they must be discharged from the program." In practice, the Facility Director reported that the counselors are to send an engagement letter, giving thirty days of notice of potential discharge, then discharge the client if there is no response. The facility failed to discharge clients due to lack of engagement and attendance according to the specified timeframes in three of seven records reviewed. Due to the facility not discharging those clients, those clients were considered active and therefore missing all required documentation for a period of the treatment episode.Client # 2 was admitted on September 26, 2023 and was active at the time of the inspection. The client last attended a treatment session on December 14, 2023.Client # 3 was admitted on February 26, 2024 and was active at the time of the inspection. The client last attended a treatment session on February 26, 2024.Client # 4 was admitted on October 26, 2023 and was discharged on June 4, 2024. The client last attended a treatment session on February 9, 2024.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Responsible Party: Program Director or Designee
Plan of Correction:
Action:
o Program Director reviewed 711.92(a)(3) Mngt of Treatment Services: (a) The project shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to written procedures for the development, approval and ongoing management of treatment/rehabilitation services for clients.
o The program Director reeducated program staff on policy by rounding with staff on 8/09/2024.
o The Program Director assigned counselors chart auditing responsibilities, which required them to review closed charts within the past 30 days to verify adherence to standards for all of their assigned patients.
o Self-auditing of charts by counselors will be outlined as an expectation of the counselor's role and responsibilities, which counselors signed off on understanding on 8/09/24.
o Any charts that need to be discharged will be complied by 8/23/24. The program Director or designee will audit for compliance.
o 20 discharged charts/month will be audited for verification of discharge protocol compliance until six months of sustained compliance at 100% is achieved.
o The Program Director or designee will perform chart audits to verify that the counselors adhere to their weekly chart audit responsibilities.
o The Program Director or will report results to the Penn Presbyterian Medical Center (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.
o Client #1, Client #2, Client #3
& Client #4 records noted in findings were discharged from the program at the time of review, and no further action could be taken on the charts to meet the timeframes outlined in discharge procedures.
|
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.
|
Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in three of three applicable records reviewed. Client # 5 was admitted on October 3, 2023 and was discharged on January 19, 2024. There was no documentation of follow-up information in the record.Client # 6 was admitted on August 31, 2023 and was discharged on February 23, 2024. There was no documentation of follow-up information in the record.Client # 7 was admitted on April 5, 2024 and was discharged on April 25, 2024. There was no documentation of follow-up information in the record.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Responsible Party:
Program Director or designee
Action:
o 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, including information about the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include follow-up information: ensure a complete client record includes information relative to the client's involvement with the project, including follow-up information.
o The program Director reviewed the policy with the team and found that no changes to the policy were required to meet the intent of the regulation. The Director re-educated program staff on the policy to include rounding with staff on 8/09/2024 to reinforce critical aspects of the policy and procedure to ensure compliance
o The Program Director assigned counselors chart auditing responsibilities, which required them to review all active client charts and any closed charts within the past 30 days for adherence to standards for all of their assigned patients.
o Counselors' self-auditing of charts was outlined as an expectation of their role and responsibilities, which counselors signed off on understanding on 8/09/24.
o Any active charts that need to comply with appropriate follow-up information or discharged clients within the past 30 days requiring follow-up will be brought into compliance by 8/23/24. If follow-up cannot occur due to a lack of contact information, that will be noted in the chart under the phone, not in case management notes. The Program Director or designee will audit for compliance.
o 10 current and 10 discharged charts/month will be audited for verification of follow-up protocol compliance until six months of sustained compliance at 100% is achieved.
o The Program Director or designee will perform chart audits to verify the counselors adhere to their weekly chart audit responsibilities.
o The Program Director or designee 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.
o Client #5, Client #6, Client #7 records noted in the findings were discharged from the program at the time of review, and no further action could be taken on the charts to meet the timeframes outlined in follow-up procedures.
|
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
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:
|
Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in each record reviewed. Client # 1 was admitted on October 24, 2023 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on October 24, 2023, did not allow for the release of that information.Client # 2 was admitted on September 26, 2023 and was active at the time of the inspection. There was evidence of a disclosure to a family member during a family counseling session on December 14, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.Client # 3 was admitted on February 26, 2024 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on February 26, 2024, did not allow for the release of that information.Client # 4 was admitted on October 26, 2023 and was discharged on June 4, 2024. Per a discussion with the Facility Director, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on October 26, 2023, did not allow for the release of that information. Additionally, there was evidence of a disclosure to a family member during a family counseling session on December 18, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.Client # 5 was admitted on October 3, 2023 and was discharged on January 19, 2024. Per a discussion with the Facility Director, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on October 3, 2023, did not allow for the release of that information. Client # 6 was admitted on August 31, 2023 and was discharged on February 23, 2024. Per a discussion with the Facility Director, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on August 31, 2023, did not allow for the release of that information. Client # 7 was admitted on April 5, 2024 and was discharged on April 25, 2024. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing. These findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Responsible Party:
Program Director or designee
Action:
o Program Director reviewed 711.93(c)(2) Consent to Release-Informed & Voluntary: 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: obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in each record reviewed.
o The Program Director reviewed the policy with the team and found no changes to the policy were required to meet the intent of the regulation. The Director re-educated program staff on the policy and consent to release information including rounding with staff on 8/09/2024, to reinforce critical aspects of the policy and procedure to ensure compliance
o Consent to release information for funding sources will be completed by admission staff upon admission. This was reviewed in rounding with admission team members, who signed off on understanding on 8/09/24.
Before any individual joins a client in their scheduled session, a consent to release information will be completed by the counselor with the client. This was reviewed in rounding with counselors, who signed off on understanding on 8/09/24.
o The Program Director assigned counselors chart auditing responsibilities, which required them to review all active client charts to verify adherence to consent standards for all of their assigned patients.
o Self-auditing of charts by counselors will be outlined as an expectation of the counselor's role and responsibilities, which counselors signed off on understanding on 8/09/24.
o Any active charts that need to be brought into compliance with appropriate consents by 8/23/24. The Program Director or designee will audit for compliance.
o 20 active charts/month will be audited for verification of consent protocol compliance until six months of sustained compliance at 100% is achieved.
o The Program Director or designee will perform chart audits to verify that the counselors adhere to their weekly chart audit responsibilities.
o The Program Director or 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.
o Client #1's chart was updated to ensure consent to releasing information to the funding source.
o Client #2's chart was updated to include consent to release information to family members so that they could participate in family sessions.
o Client #3's chart was updated to ensure consent to releasing information to the funding source.
o Client #4, Client #5, Client #6, and Client #7's charts were discharged at the time of review, and an update could not be made to the closed chart to ensure consent to release information to the funding source to meet the timeframes outlined in procedures.
|