INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on February 24, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Penndel Mental Health 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:
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Plan of Correction
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709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent form from the client for the disclosure of information contained in the client record in seven of seven client records reviewed.
Client #1 was admitted February 24, 2020 and was active at the time of inspection. There was documentation of billing to the funding source; however, there was no consent form documented in the record prior to the disclosure of information.
Client #2 was admitted on December 9, 2019 and was active at the time of inspection. There was documentation of billing to the funding source; however, there was no consent form documented in the record prior to the disclosure of information.
Client #3 was admitted February 5, 2020 and was active at the time of inspection. There was documentation of billing to the funding source; however, there was no consent form documented in the record prior to the disclosure of information.
Client #4 was admitted April 13, 2020 and was discharged October 27, 2020. There was documentation of billing to the funding source; however, there was no consent form documented in the record prior to the disclosure of information.
Client #5 was admitted May 15, 2020 and was discharged August 27, 2020. There was documentation of billing to the funding source; however, there was no consent form documented in the record prior to the disclosure of information.
Client #6 was admitted July 23, 2019 and was discharged September 14, 2020. There was documentation of billing to the funding source; however, there was no consent form documented in the record prior to the disclosure of information.
Client #7 was admitted August 17, 2020 and was discharged January 18. 2021. There was documentation of billing to the funding source; however, there was no consent form documented in the record prior to the disclosure of information.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Penndel Mental Health Center (PHMC) has instructed staff (front desk, intake assessors, and clinicians), through supervision and trainings that releases of information (ROI) are to be individually specific to the funding source (Payor) for each individual client. Management, director, clinical supervisor, and coordinators, through supervision and chart audits will maintain the oversight of this practice effective immediately (3/19/2021). |
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
Based on a review of client records the facility failed to keep release of information forms that allow for the disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in two of seven client records reviewed.
Client #1 was admitted February 24, 2020 and was active at the time of inspection. There was a consent to release information form to a government agency, signed and dated by the client, that allowed for "All" information to be released, which exceeds the limits established by 4 Pa. Code 255.5.
Client #7 was admitted August 17, 2020 and was discharged January 18. 2021. There was a consent to release information form to a government agency, signed and dated by the client, that allowed for "All" information to be released, which exceeds the limits established by 4 Pa. Code 255.5.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Penndel Mental Health Center (PHMC) has instructed staff (front desk, intake assessors, and clinicians), through supervision and trainings that releases of information (ROI) are to be individually checked off specifically stating which is allowed to be released and that check all box is never to be utilized for clients. Management, director, clinical supervisor, and coordinators, through supervision and chart audits will maintain the oversight of this practice effective immediately (3/19/2021). |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the frequency of services on all treatment plans in seven of seven client records reviewed.
Client #1 was admitted February 24, 2020 and was active at the time of inspection. The comprehensive treatment plan was completed on February 24, 2020 and did not include the frequency of services provided.
Client #2 was admitted on December 9, 2019 and was active at the time of inspection. The treatment plan update was completed on December 9, 2019 and did not include the frequency of services provided.
Client #3 was admitted February 5, 2020 and was active at the time of inspection. The comprehensive treatment plan was completed on March 5, 2020 and did not include the frequency of services provided.
Client #4 was admitted April 13, 2020 and was discharged October 27, 2020. The comprehensive treatment plan was completed on April 13, 2020 and did not include the frequency of services provided.
Client #5 was admitted May 15, 2020 and was discharged August 27, 2020. The comprehensive treatment plan was completed on May 15, 2020 and did not include the frequency of services provided.
Client #6 was admitted July 23, 2019 and was discharged September 14, 2020. The comprehensive treatment plan was completed on July 23, 2019 and did not include the frequency of services provided.
Client #7 was admitted August 17, 2020 and was discharged January 18. 2021. The comprehensive treatment plan was completed on August 17, 2020 and did not include the frequency of services provided.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Penndel Mental Health Center (PHMC) has instructed clinicians, through supervision and trainings that treatment plans are to be specific and include the frequency of the treatment modalities: i.e. Intensive Outpatient (IOP) group 3x a week and individual 2x a week and General Outpatient (GOP) group 1x a week and individual 1x a week. Management, director, clinical supervisor, and coordinators, through supervision and chart audits will maintain the oversight of this practice effective immediately (3/19/2021). |
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 the review of client records, the facility failed to ensure that all treatment plans were reviewed and updated at least every 60 days in six of seven client records reviewed.
Client #1 was admitted February 24, 2020 and was active at the time of inspection. A treatment plan update was completed on April 4, 2020 and the next update was due no later than June 4, 2020. However, the update was not completed at the time of inspection.
Client #2 was admitted on December 9, 2019 and was active at the time of inspection. A treatment plan update was completed on August 24, 2020 and the next update was due no later than October 24, 2020. However, the update was not completed until December 7, 2020. Additionally, a treatment plan update was completed December 7, 2020 and the next update was due no later than February 7, 2021. However, the update was not completed at the time of inspection
Client #3 was admitted February 5, 2020 and was active at the time of inspection. The comprehensive treatment plan was completed on March 5, 2020 and an update was due no later than May 5, 2020. However, the update was not completed until May 28, 2020. Additionally, a treatment plan update was completed May 28, 2020 and the next update was due no later than July 28, 2020. However, the update was not completed at the time of inspection
Client #4 was admitted April 13, 2020 and was discharged October 27, 2020. The comprehensive treatment plan was completed on April 13, 2020 and a treatment plan update was due no later than June 13, 2020. However, the update was not completed until August 31, 2020.
Client #6 was admitted July 23, 2019 and was discharged September 14, 2020. A treatment plan update was completed on March 11, 2020 and the next update was due no later than May 11, 2020. However, the update was not completed prior to the client's discharge.
Client #7 was admitted August 17, 2020 and was discharged January 18. 2021. The comprehensive treatment plan was completed on August 17, 2020 and a treatment plan update was due no later than October 17, 2020. However, the treatment plan update was not completed prior to the client's discharge.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Penndel Mental Health Center (PHMC) has instructed clinicians, through supervision and trainings that treatment plans are to be reviewed, updated, and executed for clients at 60 day intervals while clients are in the care of the facility. Management, director, clinical supervisor, and coordinators, through supervision and chart audits will maintain the oversight of this practice effective immediately (3/19/2021). |