INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 19, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mercy Behavioral Health 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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709.92(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 applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in two of six records.Client #1 was admitted to the outpatient program on August 31, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on September 22, 2022. A treatment and rehabilitation plan update was due no later than November 22, 2022, but was not completed until March 14, 2023.Client #3 was admitted to the outpatient program on May 25, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on January 10, 2023. A treatment plan update was due no later than March 10, 2023, but was not completed until March 21, 2023.This is a repeat citation from the May 16-18, 2022, June 2, 2021, October 26, 2020 and May 8, 2019 licensing inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment and rehabilitation plans will be reviewed and updated per regulations. Program Administrators/Clinical Leads will review with colleagues during monthly supervision. Program Administrators/Clinical Leads/Colleagues will conduct monthly chart audits to ensure regulations are followed. Colleague training will be provided by 6/30/2023 on the regulation/timeline requirement and on utilizing the EHR widget "Treatment Plan Upcoming Reviews" as the notification system for identifying treatment plan reviews that are due. Program Administrators/Clinical Leads/Colleagues will each audit a minimum of (1) SUD client chart per SUD clinician monthly to ensure the Plan of Correction is implemented. Staff retraining will occur as needed based on audit findings. |
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 applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in three of five records. The facility policy and procedure manual indicate a case consultation to occur quarterly for the first year of services and then annually thereafter. Client #1 was admitted to the outpatient program on August 31, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than November 30, 2022, however no case consultations have been completed.Client #3 was admitted to the outpatient program on May 25, 2022 and was still active at the time of the inspection. A case consultation was completed on July 12, 2022. A case consultation was due to occur no later than October 12, 2022, however this was not completed until January 4, 2023.This is a repeat citation from the May 16-18, 2022, June 2, 2021 and October 26, 2020 licensing inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Administrators/Clinical Leads or designee will conduct case consultations with therapists on new persons served quarterly for the first year of services and then annually thereafter. Case consultations will be documented in the EHR utilizing the "Care Coordination" document. Program Administrator, in conjunction with Information Technology Department, will explore EHR "widgets" for tracking Coordination of Care documentation in the record, including a notification alert system to flag reviews prior to the identified time frame. Therapists will be retrained on case consultation requirements by 6/30/2023. Therapists will be trained to use the new tracking method upon its development. Program Administrators/Clinical Leads/Colleagues will each audit a minimum of (1) SUD client chart per SUD clinician monthly to ensure the Plan of Correction is implemented. Staff retraining will occur as needed based on audit findings. |
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 client records, the facility failed to comply with plans of correction that were approved by the Department. Plans of correction for treatment plan updates were submitted and approved by the Department for the May 16-18, 2022, June 2, 2021, October 26, 2020 and May 8, 2019 licensing inspections. Treatment plan updates were again found to be a deficiency in the April 19, 2023 licensing inspection.Plans of correction for case consultations were submitted and approved by the Department for the May 16-18, 2022, June 2, 2021 and October 26, 2020 licensing inspections. Case consultations were again found to be a deficiency in the April 19, 2023 licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pittsburgh Mercy will adhere to the approved Plan of Correction. Program Administrators/Clinical Leads/Colleagues will conduct random chart audits to ensure the plan of correction is being implemented. Training will be held to refresh colleague's familiarity with audit tool. Program Administrators/Clinical Leads/Colleagues will each audit a minimum of (1) SUD client chart per SUD clinician monthly to ensure the Plan of Correction is implemented. Staff retraining will occur as needed based on audit findings. |