INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 7 - 8, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
The facility is publicly funded and failed to make available to the public the July 1, 2017 - June 30, 2018 annual report based on a review of the facility's policies, procedures and administrative materials conducted on May 7 - 8, 2019.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.22 (c) As a publicly funded facility, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable. This annual report will be published and available to the public after June 30, 2019 for the fiscal year dated July 1, 2018 through June 30, 2019. Once published, the Facility Director will be responsible to insure the annual report is available for review an on-site licensure renewal inspection.
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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
The facility failed to provide documentation that the annual written staff performance evaluations were reviewed and signed by the employee in three of five personnel records reviewed on May 8, 2019.The annual performance evaluations for the following employees were documented but did not include their signature.Employee # 1 was hired on February 16, 2015. The performance evaluation was completed July 2018.Employee # 2 was hired on July 15, 2015. The performance evaluation was completed March 2019.Employee # 3 was hired on August 22, 2016. The performance evaluation was completed February 2019.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.26 (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. By July 1, 2019, the Pittsburgh Mercy annual performance evaluation will have a signature and date line added to it to indicate it has been reviewed.
The Facility Director will be responsible to insure the annual evaluations are dated and signed by the employee beginning July 1, 2019 and on-going.
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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
The facility failed to document the review and update of treatment and rehabilitation plans at least every sixty days in four of seven client records reviewed on May 7 - 8, 2019.Client # 4 was admitted October 1, 2018. The treatment plan was completed October 1, 2018. The only treatment plan updates were documented December 17, 2018 and February 27, 2019.Client # 5 was admitted September 28, 2018. The treatment plan was completed September 28, 2018. The only treatment plan update was documented January 8, 2019.Client # 6 was admitted December 20, 2018. The treatment plan was completed December 20, 2018. The only treatment plan update was documented May 1, 2019.Client # 7 was admitted August 14, 2018 and discharged January 29, 2019. The treatment plan was documented August 14, 2018. The only treatment plan update was documented September 10, 2018.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92. Treatment and rehabilitation services. (b) 709.92. Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
Clinical supervisors will train staff on the requirement of treatment and rehabilitation plans shall be reviewed and updated at least every 60 days, along with providing a tracking tool to be used to record due dates of treatment and rehabilitation plan due dates. This training will be completed by June 1, 2019 and documented in clinical supervision notes, and repeated for new hires on-going.
Clinical supervisors will monitor the due dates of treatment and rehabilitation plans by using a report from the electronic health report. The report information will be shared and used in clinical supervision with staff that are responsible for creating treatment and rehabilitation plans with clients.
Clinical Supervisors will conduct monthly documented internal audits of client records to verify treatment and rehabilitation plans are reviewed and updated at least every 60 days.
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