INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23 - 24, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Psychiatric Institute was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of employee training records on April 23, 2018, the facility failed to document the completion of at least 6 hours of HIV/AIDS and 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training for Employee #2. Employee #2 was hired on August 1, 2016 and was to receive this training by August 1, 2017.
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Plan of Correction
L0067: HIV/AIDS (6 hours) Training will be added to new staff orientation checklist to ensure that all staff will be scheduled and trained within the first year of employment for all counselor and counselor assistants and within the first two (2) years of employment of all other staff. All training intended to satisfy this regulatory requirement must fall within the acceptable criteria of the Department of Drug and Alcohol's approved curriculum.
TB/STD (4 hours) Training will be added to new staff orientation checklist to ensure that all staff will be scheduled and trained within the first year of employment for all counselor and counselor assistants and within the first two (2) years of employment of all other staff. All training intended to satisfy this regulatory requirement must fall within the acceptable criteria of the Department of Drug and Alcohol's approved curriculum.
The Program Manager will review the checklist within the first 90 days of employment and monthly thereafter to ensure training compliance.
The following will address the current staff training needs: Two (2) counselors and the Facility Director are scheduled to attend a six (6) hour HIV/AIDS training in Philadelphia on June 13, 2018. The remaining staff will be trained through the Dauphin County's Single County Authority (SCA). Per telephone inquiry with Dauphin County SCA on May 22, 2018, TB/STD/HIV/AIDS training for all AIR program staff will be provided by the Dauphin County SCA before October 2018. All AIR Program Counselors, Counselor Assistants and all currently employed AIR program staff will attend the trainings.
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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 a review of client records on April 24, 2018, the facility failed to document a timely treatment plan update in three out seven client records.
The findings include:
Client #1 was admitted on November 13, 2017 and is still in treatment. A treatment plan updated was due on 2/11/18 but was not completed until 3/7/18.
Client #2 was admitted on December 11, 2018 and is still in treatment. A treatment plan update was due on 3/15/18 but was not completed until 4/13/18.
Client #4 was admitted on November 16, 2017 and is still in treatment. A treatment plan update was due on 3/17/2018, but was not completed until 4/12/18.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L1883: It is the expectation per the AIR Program policy, AIR 2.9 Treatment Planning that the treatment plan will be reviewed and updated every 60 days.
The Facility Director provided training to all clinical staff on May 24, 2018 addressing individual treatment plans, and the mandate that treatment plans must be reviewed and updated every 60 days.
Beginning May 2018, Chart Audits will be completed by Program Director on a monthly basis to review for compliance.
Audit results will be reported out in a monthly staff meeting as a reoccurring agenda item. Staff deficient in this area will be identified for intensive retraining and performance coaching.
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