INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and Buprenorphine monitoring conducted on January 6, 2020 to January 9, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Penn Foundation, Inc. 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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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
The facility failed to ensure that three applicable employees did not exceed the outpatient 35 to 1 FTE counselor to client ratio. The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.Employee # 9 was hired as a counselor on June 19, 2017. The ratio calculation was as follows: 8/40 = 0.2(FTE); 8/0.2 = 40, which equals to a client/counselor ratio of 40:1.Employee # 13 was hired as a clinical supervisor on January 7, 2019. The ratio calculation was as follows: 8/40 = 0.2(FTE); 11/0.2 = 55, which equals to a client/counselor ratio of 55:1.Employee # 17 was hired as a counselor on March 18, 2019. The ratio calculation was as follows: 16/40 = 0.4(FTE); 14/0.4 = 40, which equals to a client/counselor ratio of 40:1. Employee # 22 was hired as a counselor on July 8, 2013. The ratio calculation was as follows: 8/40 = 0.2(FTE); 8/0.2 = 40, which equals to a client/counselor ratio of 40:1.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 2/1/2020, clinical supervisor will support staff with having caseloads adjusted to fit into ratios identified, moving forward clinical supervisor will monitor case load and complete computation on a monthly basis to assure part time staff are within the regulated ratios for active cases. This will also be reviewed in supervision with the staff identified. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The facility failed to document that fire drills were conducted during sleeping hours at least every 6 months for the months of January 2019 to December 2019. There were no fire drills conducted during sleeping hours for the time reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The maintenance department was educated on the need to conduct a overnight/sleeping fire drill at least ever 6 months for the non hospital unit.
The Inpatient program director will review fire drills once every 5 months to assure the process is implemented. The next fire drill for this project will be done overnight for inpatient services. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
The facility failed to include the specific information that was to be disclosed on a consent to release information form in 2 of 29 client records.Client # 5 was admitted to the detoxification level of care on January 2, 2020 and was active at the time of the inspection. There was a consent to release information form to a family member signed and dated by the client on January 6, 2020; however, it did not include the specific items to be released.Client # 18 was admitted to the partial hospitalization level of care on October 1, 2019 and was discharged on October 25, 2019. There were two consent to release information forms to an individual and a primary care physician signed and dated by the client on September 24, 2019 and September 27, 2019; however, the forms identified " other " information to be released without specifying the details of the information to be released. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff responsible for completing release of information forms will be re-trained by their direct supervisor in completion of releases of confidential information to ensure releases are fill out correctly and completely according to regulatory standards and include information to be disclosed. Training will be completed by 2/5/2020. Compliance will be monitored through quarterly chart audits conducted by the Program Director and Compliance Officer.
Identified deficient records will be attempted to be corrected by Supervisor making arrangement for outreach to identified person via in person, by mail, or by telephone. |
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
The facility failed to document the purpose of disclosure on a consent ot release information form in 8 of 29 client records.Client # 5 was admitted to the detoxification level of care on January 2, 2020 and was active at the time of the inspection. There was a consent to release information form to a family member and to a government agency signed and dated by the client on January 6, 2020; however, both did not include the purpose for disclosure.Client # 8 was admitted to the detoxification level of care on March 21, 2019 and was discharged on March 28, 2019. There were three consent to release information forms to three individuals signed and dated by the client on March 27, 2019; however, they did not include the purpose for disclosure.Client # 10 was admitted to the detoxification level of care on November 20, 2019 and was discharged on November 25, 2019. There was a consent to release information form to a pharmacy signed and dated by the client on November 20, 2019; however, it did not include the purpose for disclosure.Client # 12 was admitted to the residential level of care on March 28, 2019 and was discharged on April 11, 2019. There were three consent to release information forms to three individuals signed and dated by the client on March 27, 2019; however, they did not include the purpose for disclosure.Client # 15 was admitted to the residential level of care on November 26, 2019 and was active at the time of the inspection. There were three consent to release information forms to a pharmacy, an individual and a health center signed and dated by the client on November 20, 2019, November 26, 2019 and December 3, 2019; however, they did not include the purpose for disclosure.Client # 18 was admitted to the partial hospitalization level of care on October 1, 2019 and was discharged on October 25, 2019. There were two consent to release information forms to an individual and a primary care physician signed and dated by the client on September 24, 2019 and September 27, 2019; however, the forms listed " other " with no specification of the purpose for disclosure.Client # 21 was admitted to the partial hospitalization level of care on December 27, 2019 and was active at the time of the inspection. There were four consent to release information forms to four individuals signed and dated by the client on December 12, 2019; however, they did not include the purpose for disclosure.Client # 24 was admitted to the outpatient level of care on April 11, 2019 and was discharged on December 12, 2019. There were three consent to release information forms to three individuals signed and dated by the client on March 27, 2019; however, they did not include the purpose for disclosure.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff responsible for completing consent to release of information forms will be re-trained by their direct supervisor in completion of releases of confidential information to ensure releases are fill out correctly and completely according to regulatory standards and include information to be disclosed. Training will be completed by 2/5/2020. Compliance will be monitored through quarterly chart audits conducted by the Program Director and Compliance Officer. For the ones identified with concerns outreach will occur via phone call and letter to attempt to correct these deficient releases. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
The facility failed to document the dated signature of a client on a consent to release information form in 1 of 29 client records.Client # 23 was admitted to the outpatient level of care on July 12, 2019 and was active at the time of the inspection. There was a consent to release information form to a funding source signed and dated by the witness on May 28, 2019; however, the consent form did not include dated client signature. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff responsible for completing release of information forms will be re-trained by their direct supervisor in completion of releases of confidential information to ensure releases are filled out correctly and completely according to regulatory standards and include the purpose of the disclosure. Training will be completed by 2/5/2020. Compliance will be monitored through quarterly chart audits conducted by the Program Director and Compliance Officer.
All staff responsible for completing release of information forms will be re-trained by their direct supervisor in completion of releases of confidential information to ensure releases are fill out correctly and completely according to regulatory standards and include the purpose of the disclosure. Training will be completed by 2/5/2020. Supervisors will make arrangements to correct the identified consent that was deficient will be corrected by attempting to outreach person in person, mail, or by phone contact in order to make arrangements to obtain the signature. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
The facility failed to document the dated signature of a witness on a consent to release information form in 2 of 29 records.Client # 10 was admitted to the detoxification level of care on November 20, 2019 and was discharged on November 25, 2019. There were four consent to release information forms to a pharmacy, government agency, funding source and individual and signed and dated by the client on November 20, 2019; however, the consent forms did not include the dated witness signatures.Client # 15 was admitted to the residential level of care on November 26, 2019 and was active at the time of the inspection. There were four consent to release information forms to a pharmacy, government agency, funding source and individual and signed and dated by the client on November 20, 2019; however, the consent forms did not include the dated witness signatures.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff responsible for completing release of information forms will be re-trained by their direct supervisor in completion of releases of confidential information to ensure releases are fill out correctly and completely according to regulatory standards and include a witness signature. Training will be completed by 2/5/2020. Compliance will be monitored through quarterly chart audits conducted by the Program Director and Compliance Officer.
All identified deficient charts from this survey will attempted to be corrected by the supervisor assuring in person, mail, or telephone outreach to fix the releases. Attempts will be documented within the health record. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
The facility failed to notify the Department within 3 days following an unusual incident, which involved client deaths that were reported to the facility on the following dates:January 11, 2019March 12, 2019July 15, 2019September 13, 2019These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Penn Foundation realized that there was a break down in the reporting of unusual incidents process. We resolved our process of reporting of Unusual Incidents to DDAP in November 2019 and have been working diligently on completing the submission of these incident reports within 3 days following an unusual incident to DDAP. This new process was reviewed with both Program Directors by the Vice President of Clinical Services and has since been changed. Penn Foundation has been filing these reports out electronically. All incidents requiring back entry were submitted in November via electronic submission. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to notify the Department within 3 business days following the unusual incidents below, which were discovered during the licensing process.The incident dates and incident reasons are:July 11, 2019 - Police presence requestedNovember 6, 2019 - Ambulance presence requestedNovember 27, 2019 - Ambulance presence requestedThese findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Penn Foundation realized that there was a break down in the reporting of unusual incidents process . We resolved our process of reporting of Unusual Incidents to DDAP in November 2019 and have been working diligently on completing the submission of these incident reports within 3 days following an unusual incident to DDAP. This new process was reviewed with both Program Directors by the Vice President of Clinical Services and has since been changed. Penn Foundation has been filing these reports out electronically. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
The facility failed to document that an individual treatment and rehabilitation plan was developed with the client in one of five applicable client records reviewed. Additionally, the facility failed to document which types of services and the frequency the client was to receive those services on the client's individual treatment plan in four of five applicable client records reviewed. Client # 18 was admitted to the partial hospitalization level of care on October 1, 2019 and was discharged on October 25, 2019. The comprehensive treatment plan was dated October 13, 2019. The type and frequency of services was not listed on the treatment plan. Client # 19 was admitted to the partial hospitalization level of care on October 3, 2019 and was discharged on October 22, 2019. The record did not contain a comprehensive treatment plan.Client # 20 was admitted to the partial hospitalization level of care on December 27, 2019 and active at the time of the inspection. The comprehensive treatment plan was dated January 6, 2020. The type and frequency of services was not listed on the treatment plan. Client # 21 was admitted to the partial hospitalization level of care on December 27, 2019 and active at the time of the inspection. The record did not contain a comprehensive treatment plan.Client # 22 was admitted to the partial hospitalization level of care on December 20, 2019 and active at the time of the inspection. The comprehensive treatment plan was dated January 6, 2020. The type and frequency of services was not listed on the treatment plan. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 2/15/2020 Program Director is developing a new process to the treatment plan template in the electronic health record to include check off boxes which will prompt the clinician to check off "types of services" and "frequency of these services" These options will be required for the clinicians to fill out before their signature. Clinical Supervisor will complete random charts audits to check for completion of this by clinical staff and will address in individual supervisions.
You can not go back in deficient charts to create treatment plans that do not pertain to a client not currently in service. This corrective action will prevent further deficiencies moving forward. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to include documentation that the facility informed female clients of the potential risks to her or her unborn child of continued use of illicit drugs, or withdrawal from a narcotic drug prescribed by the program in two of seven applicable patient records.Patient # 23 was admitted to the outpatient level of care on July 12, 2019 and was active at the time of the inspection.Patient # 27 was admitted to the outpatient level of care on June 13, 2019 and was active at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 2/15/2020 the Medical Director will review in Supervision with the Medical staff that for all women, or pregnant women and women of child bearing age etc, the patient is to be fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of or withdrawal from a narcotic drug administered or dispensed by the Outpatient Program. A new process will be implemented in our electronic health record which will automatically pull the consent onto the prescribers' to do list, to complete with the patient prior to induction. Clinical Supervisor will complete random chart audits, and findings will be reviewed with Program Director and Medical Director. |
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
The facility failed to provide treatment plan updates within the regulatory timeframe in three of four applicable client records reviewed.Client # 24 was admitted to the outpatient level of care on April 11, 2019 and was discharged on December 12, 2019. The comprehensive treatment and rehabilitation plan was completed on August 14, 2019 with an update due no later than October 14, 2019; however, no update was completed prior to discharge.Client # 27 was admitted to the outpatient level of care on June 13, 2019 and active at the time of the inspection. A treatment plan update was completed on August 15, 2019 with an update due no later than October 15, 2019; however, the update was not completed until December 26, 2019.Client # 29 was admitted to the outpatient level of care on January 14, 2019 and was discharged on May 23, 2019. A treatment plan update was completed on February 8, 2019 with an update due no later than April 8, 2019; however, the update was not completed until May 10, 2019These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 2/15/2020 Clinical Supervisor will review with clinicians in group supervision the importance of completing treatment plan updates on time. Clinicians will be given a copy of Penn Foundations policy and procedure on treatment plan updates and abide by the policy. Clinical Supervisor will complete random chart audits to check for accuracy and compliance with the regulation. |
709.93(a) 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:
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Observations
The facility failed to provide a complete client record in four of seven client records.Client # 23 was admitted to the outpatient level of care on July 12, 2019 and was active at the time of the inspection. The facility failed to ensure that the client signed an informed consent to treat prior to the administration of a narcotic agent. The client's initial dose was on August 28, 2019, but there was no informed consent to treat form on file.Client # 24 was admitted to the outpatient level of care on April 11, 2019 and was discharged on December 12, 2019. The record did not contain documentation of follow up.Client # 27 was admitted to the outpatient level of care on June 13, 2019 and was active at the time of the inspection. The facility failed to ensure that the client signed an informed consent to treat prior to the administration of a narcotic agent. The client's initial dose was on July 11, 2019, but there was no informed consent to treat form on file.Client # 28 was admitted to the outpatient level of care on April 10, 2019 and was discharged on June 17, 2019. The record did not contain documentation of follow up.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 2/15/2020 the Medical Director will review with the Prescribers in group supervision the regulation of completing the Buprenorphine Consent to treatment with the client prior to the Suboxone induction. By 2/15/2020 a new process will be implemented in our electronic health record which will automatically pull the consent onto the prescribers' to do list, to complete with the patient prior to induction.
Medical staff will obtain consent for identified charts of persons still active in care. |