INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 14, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PHMC Pathways to Recovery 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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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on an administrative review, the project failed to ensure that the project director annually updated and signed the written manual delineating the project's policies and procedures. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project director reviewed and signed the written manual on 8/9/2022. The project director implemented a Microsoft Outlook reminder system to update and sign the written policy and procedure manual at minimum once annually in the month of January. The PHMC BHS Program Manager will ensure that the reminder is received, and the task is completed by the Project Director annually minimally during the month of January. The PHMC Quality Management team will review policy and procedure update signatures as part of pre-licensing inspection reviews and report compliance and any findings for follow-up to the Project Director and BHS Managing Director. |
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 document the specific information to be disclosed on consent to release information forms in two of seven client records reviewed. Client # 2 was admitted on May 18, 2022 and was still active at the time of the inspection. The release of information form to a disability attorney was signed and dated by the client on June 21, 2022, but there was no specific information to be disclosed documented on the release form. Client # 4 was admitted on November 15, 2021 and was discharged on February 14, 2022. The release of information forms to several other treatment providers, a government agency, a family member, and a co-worker were all signed and dated by the client and on November 15, 2021, but the specific information to be disclosed was not documented on any of the release forms. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will review staff Individual training plans to ensure that all required staff have completed DDAP Confidentiality training, which includes instruction for obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record in writing and including, but not be limited to, specific information disclosed; as required by 709.28 (c) (2) LICENSURE. All required staff will complete DDAP Confidentiality training within 180 days of hire.
Project Director will review 709.28 (c) (2) requirements during the August 2022 staff meeting. Clinical Director or Project Director will review and ensure that all releases completed by staff will include specific information to be disclosed and document on release form.
The release for Client #2 will be corrected to reflect the specific information being disclosed and updated by 8/31/22.
Expected completion date 8/31/2022.
PHMC's Quality Management team will review the written consent to release information documents in the client files during regular chart reviews (e.g. quarterly), and will and report compliance with 709.28 (c) (2) and any findings for follow-up to the Project Director and BHS Managing Director.
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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
Based on a review client records, the facility failed to document the purpose of the disclosure on release of information forms in two of seven client records reviewed.Client # 2 was admitted on May 18, 2022 and was still active at the time of the inspection. The release of information form to a disability attorney was signed and dated by the client on June 21, 2022, but there was no purpose of the disclosure documented on the release form. Client # 4 was admitted on November 15, 2021 and was discharged on February 14, 2022. The release of information forms to several other treatment providers, a government agency, a family member, and a co-worker were all signed and dated by the client on November 15, 2021, but there was no purpose of the disclosure documented on any of the release forms.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Project Director will review staff Individual training plans to ensure that all required staff have completed DDAP Confidentiality training, which includes instruction for obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record in writing and including, but not be limited to, Purpose of disclosure; as required by 709.28 (c) (3) LICENSURE . All required staff will complete DDAP Confidentiality training within 180 days of hire.
The ROI for the client #2 has been corrected and updated to state the purpose of the release of information as of 8/31. The clinical director and or Project director will review releases during supervision with staff to ensure they are properly completed.
Project Director will review 709.28 (c) (3) requirements during the August 2022 staff meeting.
Expected completion date 8/31/2022.
PHMC's Quality Management team will review the written consent to release information documents in the client files during regular chart reviews (e.g. quarterly), and will and report compliance with 709.28 (c) (3) and any findings for follow-up to the Project Director and BHS Managing Director.
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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 the dated signature of the witness on release of information forms in one of seven client records reviewed. Client # 2 was admitted on May 18, 2022 and was still active at the time of the inspection. There was a release of information form to a disability attorney that was signed by the client on June 21, 2022; however, the dated signature of the witness was not documented on the release form. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director will review staff Individual training plans to ensure that all required staff have completed DDAP Confidentiality training , which includes instruction for obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record in writing and including, but not be limited to, Dated signature of witness; as required by 709.28 (c) (5) LICENSURE . All required staff will complete DDAP Confidentiality training within 180 days of hire.
The ROI for participant #2 has been corrected and updated to reflect the dated signature of the witness on the release of information. The clinical director and the project director will review releases during supervision to ensure that staff have correctly completed.
Project Director will review 709.28 (c) (5) requirements during the August 2022 staff meeting.
Expected completion date 8/31/2022.
PHMC's Quality Management team will review the written consent to release information documents in the client files during regular chart reviews (e.g. quarterly), and will and report compliance with 709.28 (c) (5) and any findings for follow-up to the Project Director and BHS Managing Director.
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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 that a copy of a client consent was offered to the client in each release of information form in two of seven client records reviewed. Client # 2 was admitted on May 18, 2022 and was still active at the time of the inspection. The release of information form to a disability attorney was signed and dated by the client on June 21, 2022, but there was no documentation that a copy of the release form was offered to the client. Client # 3 was admitted on April 27, 2022 and was still active at the time of the inspection. The release of information form to a government agency was signed and dated by the client on April 27, 2022, but there was no documentation that a copy of the release form was offered to the client. Additionally, the release of information form to a social service agency was signed and dated by the client on May 13, 2022, but there was no documentation that a copy of the release form was offered to the client. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will review staff Individual training plans to ensure that all required staff have completed DDAP Confidentiality training, which includes instruction for offering a copy of a client consent shall to the client and a copy maintained in the client record; as required by 709.28 Confidentiality (d). All required staff will complete DDAP Confidentiality training within 180 days of hire.
Project Director will share 709.28 Confidentiality (d) requirements during the August 2022 staff meeting.
Expected completion date 8/31/2022.
The ROI for participants #2 and #3 were corrected and updated to reflect documentation that a copy of the release form was offered to the client by 8/31/2022.
The Clinical Director or Project director will review the ROI's with staff during supervision to ensure that they are completed correctly.
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.Client # 6 was admitted on April 22, 2022 and was administratively discharged on May 5, 2022. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All participants at intake receive and sign for their receipt of a copy of their rights and the PHMC Grievance policy, which includes information on appealing treatment decisions like termination of services.
The termination letter template is updated to include the statement : "You have an opportunity to request reconsideration of this decision terminating treatment. We are also providing you with a grievance form and information to submit a reconsideration request/ grievance, if you so choose. " A copy of the PHMC Grievance form will be attached to the termination letter.
Project Director will share 709.33 (b) requirements and the Termination letter template during the August 2022 staff meeting.
Expected completion date 8/31/2022.
PHMC's Quality Management team will review charts for terminated participants for compliance with 709.33 (b) during regular chart reviews (e.g. quarterly), and will and report compliance and any findings for follow-up to the Project Director and BHS Managing Director.
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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 facility's July 2021 through June 2022 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following the facility ' s notification of the off-site death of a client on August 4, 2021 and the notification of an off-site death of a client on December 16, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will review staff Individual training plans to ensure that all required staff have completed the Incident and Event Reporting training course , which includes instruction for reporting of unusual incidents. All required staff will complete the Incident and Event Reporting training course within 90 days of hire and annually thereafter.
Project Director will review 709.34 (c) (2) requirements during the August 2022 staff meeting, including that 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.
Project Director will review the DDAP Electronic Reporting System (ERS) and the ERS Brochure with staff at the August 2022 staff meeting as a means of reporting unusual incidents to DDAP.
Expected completion date 8/31/2022.
PHMC's Quality Management team will review unusual incident submissions during regular chart reviews (e.g. quarterly), and will and report compliance with 709.34 (c) (2) and any findings for follow-up to the Project Director and BHS Managing Director.
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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
Based on a review of the facility's July 2021 through June 2022 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following three separate incidents that required the presence of police and/or ambulance personnel at the facility on August 13, 2021, September 28, 2021 and April 27, 2022.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will review staff Individual training plans to ensure that all required staff have completed the Incident and Event Reporting training course , which includes instruction for reporting of unusual incidents. All required staff will complete the Incident and Event Reporting training to include unusual incidents that required the presence of police and/or ambulance personnel at the facility course within 90 days of hire and annually thereafter.
Project Director will review 709.34 (c) (2) requirements during the August 2022 staff meeting, including that the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving: unusual incidents that required the presence of police and/or ambulance personnel at the facility (2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
Project Director will review the DDAP Electronic Reporting System (ERS) and the ERS Brochure with staff at the August 2022 staff meeting as a means of reporting unusual incidents to DDAP.
Expected completion date 8/31/2022.
PHMC's Quality Management team will review unusual incident submissions during regular chart reviews (e.g. quarterly), and will and report compliance with 709.34 (c) (2) and any findings for follow-up to the Project Director and BHS Managing Director.
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709.34 (c) (5) 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:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
Based on a review of the facility's July 2021 through June 2022 unusual incident logs, the facility failed to file written unusual incident reports with the Department within 3 business days following an outbreak of a contagious disease requiring CDC notification at the facility on January 7, 2022, January 8, 2022 and January 14, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will review staff Individual training plans to ensure that all required staff have completed the Incident and Event Reporting training course , which includes instruction for reporting of unusual incidents. All required staff will complete the Incident and Event Reporting training course within 90 days of hire and annually thereafter.
Project Director will review 709.34 (c) (4) requirements during the August 2022 staff meeting, including that the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving: outbreak of a contagious disease (4) Event at the facility requiring the presence of police, fire or ambulance personnel.
Project Director will review the DDAP Electronic Reporting System (ERS) and the ERS Brochure with staff at the August 2022 staff meeting as a means of reporting unusual incidents to DDAP.
Expected completion date 8/31/2022.
PHMC's Quality Management team will review unusual incident submissions during regular chart reviews (e.g. quarterly), and will and report compliance with 709.34 (c) (4) and any findings for follow-up to the Project Director and BHS Managing Director.
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every thirty days in four of five applicable client records reviewed. Client # 2 was admitted to the partial hospitalization activity on May 18, 2022 and was still active at the time of the inspection. The individual treatment plan was completed on June 8, 2022 and an update was due no later than July 8, 2022; however, the update was not completed at the time of the inspection. Client # 3 was admitted to the partial hospitalization activity on April 27, 2022 and was still active at the time of the inspection. The individual treatment plan was completed on June 8, 2022 and an update was due no later than July 8, 2022; however, the update was not completed at the time of the inspection. Client # 4 was admitted to the partial hospitalization activity on November 15, 2021 and was discharged on February 14, 2022. The individual treatment plan was completed on November 29, 2021 and an update was due no later than December 29, 2021; however, the update was not completed until January 12, 2022. Client # 5 was admitted to the partial hospitalization activity on February 22, 2022 and was discharged on May 16, 2022. The individual treatment plan was completed on March 9, 2022 and an update was due no later than April 9, 2022; however, the update was not completed until April 28, 2022. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will review 709.82 (b) requirements during the August 2022 staff meeting, including that Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. Project Director will also review the excel treatment plan tracker with staff at the August 2022 staff meeting as a means of tracking treatment plan due dates. The late treatment plans for all active clients will be updated.
Expected completion date 8/31/2022.
PHMC's Quality Management team will review treatment and rehabilitation plans during regular chart reviews (e.g. quarterly), and will and report compliance with 709.82 (b) and any findings for follow-up to the Project Director and BHS Managing Director.
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure that clients admitted to the partial hospitalization program received individual counseling services at least twice a week in six of seven applicable client records reviewed. Client # 1 was admitted on April 20, 2022 and was still active at the time of the inspection. The record of service and progress notes indicated that there were no individual counseling sessions during the weeks of May 1, 2022 through June 11, 2022 and the weeks of June 19, 2022 through the date of the inspection. Additionally, there was only 1 individual counseling session during the week of June 12, 2022 through June 18, 2022. Client # 2 was admitted on May 18, 2022 and was still active at the time of the inspection. The record of service and progress notes indicated that there were no individual counseling sessions during the week of May 22, 2022 through May 28, 2022. Client # 3 was admitted on April 27, 2022 and was still active at the time of the inspection. The record of service and progress notes indicated that there were no individual counseling sessions during the weeks of May 1, 2022 through May 21, 2022 and the weeks of June 12, 2022 through the date of the inspection. Additionally, there was only 1 individual counseling session during the weeks of May 22, 2022 through June 11, 2022. Client # 4 was admitted on November 15, 2021 and was discharged on February 14, 2022. The record of service and progress notes indicated that there were no individual counseling sessions during the week of November 21, 2021 through November 27, 2021. Client # 5 was admitted on February 22, 2022 and was discharged on May 16, 2022. The record of service and progress notes indicated that there were no individual counseling sessions during the weeks of February 27, 2022 through March 5, 2022, April 17, 2022 through April 23, 2022 and May 1, 2022 through discharge. Additionally, there was only 1 individual counseling session during the weeks of March 6, 2022 through March 12, 2022 and April 24, 2022 through April 30, 2022. Client # 7 was admitted on November 9, 2021 and was discharged on January 26, 2021. The record of service and progress notes indicated that there was only 1 individual counseling session during the week of November 21, 2021 through November 27, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will review 709.82 (d) (1) requirements during the August 2022 staff meeting, including that Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented: (1) Individual counseling, at least twice weekly. Project Director will also review the PHMC Electronic Health Record Service Report function with staff and supervisors at the August 2022 staff meeting as a means of tracking individual counseling session completions.
Expected completion date 8/31/2022.
Supervisors will review provided services during regular supervision meetings with counseling staff (e.g. weekly), and will and document compliance with 709.82 (d) (1) on staff's individual supervision notes.
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