INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16-18, 2022 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of staff training records, the facility failed to document at least 25 hours of annual training for each counselor for the 2020 - 2021 training year in one of two staff records.The facility's training year, per policy, is July 1 - June 30. The 2020 - 2021 training year was reviewed. Staff #3 was hired as a counselor on August 17, 1997. Staff #3 had documentation of 12.5 hours of training for the 2020 - 2021 training year.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the June 2, 2021 annual licensing inspection.
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Plan of Correction
Colleagues will submit (3) months of training to their supervisors for ongoing monitoring to ensure the colleague is on target to complete the required training hours. Program Administrators will review colleague training logs quarterly (reviews will be October, January, April and June). Pittsburgh Mercy training hour requirements are to complete (25) hours of training in a fiscal year (July 1st through June 30th). Program Administrators/Clinical leads will review training requirements and document in monthly supervision. All training logs will be saved quarterly on Pittsburgh Mercy's shared drive. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of staff records, the facility failed to document annual staff performance evaluations in one of two staff records.The most recent annual staff evaluations were requested for two staff. Staff #3 was hired as a counselor on August 17, 1997. The last annual performance evaluation documented for Staff #3 was completed on June 28, 2017.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the June 2, 2021 annual licensing inspection.
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Plan of Correction
Pittsburgh Mercy established a new system for annual staff performance evaluations effective 05/2022. Pittsburgh Mercy annual staff performance evaluations are completed in "Workday". Supervisors and Colleagues review and sign the annual performance evaluations in Workday. Pittsburgh Mercy annual staff performance evaluations follow the fiscal year (July 1st through June 30th). |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a review of client records and staff interviews, the facility failed to store electronic client records on a secure, password database.Client records reviewed during the May 16-18, 2022 licensing inspection were computerized records. In reviewing the drug and alcohol clients, it was noted that the mental health information could be accessed as well. It was reported during staff interview that the mental health records and drug and alchol records are together and both mental health and drug and alcohol staff have access to both. There was no separate, secure and password protected data base.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Information Technology Department is exploring options within the EHR (Electronic Health Record) to address storing electronic records on a secure, password protected database. Currently the EHR can only be accessed by colleagues who are approved and are provided with a unique username and login to the EHR. The Senior Manager of Information Technology and Senior Manager of Adult Outpatient Services met on 5/26/2022 to discuss options for the EHR. was notified of the citation on 6/13/2022. The EHR User group began discussing the citation and potential options on 6/20/2022. Pittsburgh Mercy Executive Team will need to approve the identified option. Target date for approval by Executive Team is 8/31/2022. |
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
Based on a review of client records, the facility failed to document a dated signature of the client on consents to release information in five of five client records.Client records #1, 2, 3, 4 and 5 contained signed consents to release information forms in which the client's signature was not dated.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the June 2, 2021 annual licensing inspection.
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Plan of Correction
Program Administrator met with Information Technology Department on 5/26/2022 to identify proposed change to EHR. EHR will be modified to ensure that dated signature of client or guardian is a required field in order to finalize the document. The proposed change was added to the EHR User group idea board. Anticipated implementation date in the EHR is 8/31/2022. |
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
Based on a review of client records, the facility failed to document a dated signature of the witness on consents to release information in five of five client records.Client records #1, 2, 3, 4 and 5 contained signed consents to release information forms in which the witness's signature was not dated.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the June 2, 2021 annual licensing inspection.
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Plan of Correction
Program Administrator met with Information Technology Department on 5/26/2022 to identify proposed change to EHR. EHR will be modified to ensure that dated signature of witness is a required field in order to finalize the document. The proposed change was added to the EHR User group idea board. Anticipated implementation date in the EHR is 8/31/2022. |
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 client records, the facility failed to document a copy of the client consent was offered to the client on consents to release information in three of five client records.Client records #1, 4 and 5 contained signed consents to release information forms in which a copy of the client consent was offered was not documented.Client #1 was admitted on September 13, 2021 and is currently an active client. Client record #1 contained signed consents to release information in which a copy was not offered to the client.Client #4 was admitted on September 7, 2021 and discharged March 18, 2022. Client record #4 contained signed consents to release information in which a copy was not offered to the client.Client #5 was admitted on October 26, 2021 and discharged March 17, 2022. Client record #5 contained signed consents to release information in which a copy was not offered to the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Colleagues were provided with training in January 2022, May 2022 and June 2022 that included offering and documenting the outcome of the offer of signed client consents. This training has been incorporated into new hire orientation. Program Administrators/Clinical Leads will review the requirement in colleague supervision and provide retraining as appropriate. Program Administrators/Clinical Leads/Colleagues will conduct monthly chart audits to ensure adherence to the regulation and plan of correction. |
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
Based on a review of the unusual incident reports, the facility failed to file a written unusual incident report with the Department within 3 business days following a client death.An unsual incident dated November 29, 2021 documented that a client current had passed away on November 23, 2021. There was no documentation that this incident report was filed with the Department.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/19/2022 Program Administrator and Clinical Lead reviewed the process for submitting DDAP incident reports within (3) business days as required by regulations. Unusual Incident Reports will be reported within (3) business days via the DDAP Incident Reporting website. A walkthrough guide was developed and provided to colleagues. On 5/19/2022 Senior Manager of Adult Outpatient established a process for Program Administrators/Clinical Leads to submit unusual incidents to DDAP per the regulation. |
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 a review of client records, the facility failed to document treatment plan updates at least every 60 days in five of five client records.Client #1 was admitted on September 13, 2021 and is currently an active client. A treatment plan was documented on January 20, 2022. A treatment plan update was due to be completed by March 20, 2022. The treatment plan update was not documented until April 19, 2022.Client #2 was admitted on October 31, 2021 and is currently an active client. A treatment plan was documented on November 19, 2021. There were no treatment plan updates documented in client record #2.Client #3 was admitted on November 5, 2021 and is currently an active client. A treatment plan was documented on December 28, 2021. There were no treatment plan updates documented in client record #3.Client #4 was admitted on September 7, 2021 and discharged on March 18, 2022 . A treatment plan was documented on September 16, 2021. There were no treatment plan updates documented in client record #4.Client #5 was admitted on September 7, 2021 and discharged on March 18, 2022 . A treatment plan was documented on September 16, 2021. There were no treatment plan updates documented in client record #5.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the June 2, 2021, October 26, 2020 and May 8, 2019 annual licensing inspections.
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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. Colleagues will be trained by 8/31/2022 on utilizing the EHR widget "Treatment Plan Upcoming Reviews" as the notification system for identifying treatment plan reviews that are due. |
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 a review of client records, the facility failed to document case consultations every 90 days, as per agency policy, in five of five client records.Client #1 was admitted on September 13, 2021 and is currently an active client. There were no case consultations documented in client record #1.Client #2 was admitted on October 31, 2021 and is currently an active client. There were no case consultations documented in client record #2.Client #3 was admitted on November 5, 2021 and is currently an active client. There were no case consultations documented in client record #3.Client #4 was admitted on September 7, 2021 and discharged on March 18, 2022. There were no case consultations documented in client record #4.Client #5 was admitted on October 26, 2021 and discharged on March 17, 2022. There were no case consultations documented in client record #5.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the June 2, 2021 and October 26, 2020 annual licensing inspections.
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Plan of Correction
Program Administration met with Information Technology department on 5/26/2022 to discuss a "widget" that can be developed in the EHR and this was added to the EHR User group board for further action. In the interim Program Administrators/Clinical Leads will discuss case consultations during colleague supervision at a minimum of once a month. Case consultations will be documented in the EHR utilizing the "Care Coordination" document. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facilty failed to document an aftercare plan in one of one client records.Client #4 was admitted on October 26, 2021 and successfully discharged on March 17, 2022. There was no aftercare plan documented in client record #4.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Aftercare plans will be completed according to Pittsburgh Mercy's policy (The therapist assists the patient in developing time framed plans for the recovery process reviewing the six ASAM Criteria dimensions as it relates to transfer decisions. This is accomplished during the Aftercare planning prior to discharge from treatment. A patient's aftercare plan is effective for one year following discharge. For patients discharged prior to completion of the treatment, an amended Aftercare plan is developed with the patient. It becomes the responsibility of the patient to follow up the recommendation and request information desired upon contact with other agency/therapist. For patients who have utilized the program in their fullest capacity but have been unable to complete the program, an Aftercare Plan will also be developed. Mercy Behavioral Health Services will contact clients, at 6 months, to report on progress or lack of progress or lack of progress in fulfillment of the Aftercare Plan. This contact shall be documented in the follow up file. Patient will also be asked specifically to identify any issues or concerns not yet explored. Individual or family counseling may be offered to identify and explore any identified issues. Referrals are to be made to appropriate agencies all other areas. Colleagues will review/identify aftercare plans during supervision at least monthly. All colleagues will be trained on completing aftercare plans according to policy by 8/31/2022. Program Administrators/Clinical Leads/Colleagues will conduct random chart audits to ensure the regulation is being followed. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up within 30 days of discharge, per agency policy, in two of two client records.Client #4 was admitted on September 7, 2021 and discharged on March 18, 2022. There was no follow up documented in client record #4.Client #5 was admitted on October 26, 2021 and discharged on March 17, 2022. There was no follow up documented in client record #5.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the June 2, 2021 and October 26, 2020 annual licensing inspections.
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Plan of Correction
Program Administration met with Information Technology department on 5/26/2022 to discuss a "widget" that can be developed in the EHR and this was added to the EHR User group board for further action. In the interim Program Administrators/Clinical Leads will discuss clients that were discharged and follow up information during colleague supervision at a minimum of once a month. Pittsburgh Mercy will identify and train support staff on conducting and documenting follow up calls in the EHR by 8/31/2022. All discharged clients will receive follow up contact to ensure compliance with regulations. |
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 June 2, 2021, October 26, 2020 and May 8, 2019 licensing inspections. Treatment plan updates were again found to be a deficiency in the May 16-18, 2022 licensing inspection.Plans of correction for case consultations were submitted and approved by the Department for the June 2, 2021 and October 26, 2020 licensing inspections. Case consultations were again found to be a deficiency in the May 16-18, 2022 licensing inspection.Plans of correction for follow up were submitted and approved by the Department for the June 2 and October 26, 2020 licensing inspections. Follow up was again found to be a deficiency in the May 16 - 18, 2022 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. Program Administrators/Clinical Leads/Colleagues will each audit a minimum of (1) SUD client chart monthly. |