INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 1, 2020 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, Penn Foundation Inc. 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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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
The facility failed to ensure that the FTE counselor caseload for all outpatient counselors employed did not exceed the 35 to 1 counselor to client ratio.The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.Employee #7 was hired as a counselor on March 2, 2020 and was still employed at the time of the inspection. The employee's ratio calculation was as follows: 3/40 = 0.075(FTE); 3/0.075 = 40, which equals to a client/counselor FTE ratio of 40:1.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff identified to be out of ratio with 3 hours will reduce their caseload to 2 persons, so case load ratio is maintained. One client will be requested to transfer to counselor with case load capacity. The clinical supervisor will work with the counselor on this. The clinical supervisor will monitor this staff case load capacity as part of their ongoing supervision. The Director of Outpatient will run caseload calculations bi annually to assure ongoing monitoring. |
709.28 (c) 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.
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Observations
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of twenty-eight client records reviewed.Client # 3 was admitted to the outpatient program on October 1, 2019 and was still active at the time of the inspection. The release of information form to the funding source was signed and dated by the client on August 31, 2018 and expired on August 30, 2019. However, there was evidence of billing to the funding source after the expiration date and no updated consent form was completed prior to the disclosures. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As part of our COVID emergency declaration operations signatures were not obtained and noted as so. Beginning 10/16/2020 these releases will be mailed and requested signature from the client. Moving forward all releases will be mailed when service is provided over telehealth in order to gain signatures and prevent a barrier to accessing treatment. The Director of Outpatient services will coordinate and monitor this process. |
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
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of twenty-eight client records reviewed. Client # 13 was admitted to the partial hospitalization program on February 6, 2020 and was discharged on March 2, 2020. There was a consent to release information form to the funding source signed and dated by the client on December 11, 2019, which included the release of psychiatric evaluations, treatment plans, medications, discharge summary, health summary, health and physical exam and all records 11/1/2019 through present, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Outpatient will work with the identified clinical supervisor to educate the identified staff member on the regulations around disclosure and confidentiality. The clinical supervisor will monitor this staff ongoing through their supervision to assure accurate identifications with areas of disclosure. |
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
The facility failed to document the dated signature of the client on release of information forms in two of twenty-eight client records reviewed. Client #16 was admitted to the inpatient program on March 6, 2020 and was discharged on March 30, 2020. The release of information form to the parole office was signed and dated by the witness on March 26, 2020.Client #24 was admitted to the detox program on July 17, 2020 and was discharged on July 24, 2020. The release of information forms to the funding source was signed and dated by the witness on July 15, 2020.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As part of our COVID emergency declaration operations signatures were not obtained and noted as so. Beginning 10/16/2020 these releases will be mailed and requested signature from the client. Moving forward all releases will be mailed when service is provided over telehealth in order to gain signatures and prevent a barrier to accessing treatment. The Director of Outpatient services will coordinate and monitor this process. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
The facility failed to document the date, event or condition upon which a consent to release information form would expire in two of twenty-eight client records reviewed. Client #16 was admitted to the inpatient program on March 6, 2020 and was discharged on March 30, 2020. Several release of information forms to other treatment providers were signed and dated on March 23, 2020. Several release of information forms to family members were signed and dated on March 6, 2020. Client #23 was admitted to the detox program on March 3, 2020 and was discharged on March 6, 2020. The release of information form to a lawyer was signed and dated on March 4, 2020. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Inpatient Program Director will retrain the inpatient staff on completing release of information. Staff will be educated on the need to put a end date no greater than one year. The Inpatient program Director will monitor implementation by random chart audit bi annually to assure correct implementation. |
709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
The facility failed to include documentation of a preliminary treatment plan during the intake and admission period in two of six applicable client records reviewed.Client # 12 was admitted to the partial hospitalization program on January 27, 2020 and was discharged on February 13, 2020.Client # 14 was admitted to the partial hospitalization program on February 18, 2020 and was discharged on February 25, 2020.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will orient staff to the required documentation for admission to partial hospitalization level of care and creating a preliminary treatment plan. Partial is currently suspended until determination of COVID emergency. The clinical supervisor will perform audits of this during the staffs supervision on a monthly basis. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to develop, with the client, an individual treatment and rehabilitation plan, which is to include the type and frequency of treatment and rehabilitation services, in of two of three applicable client records reviewed.Client # 9 was admitted to the partial hospitalization program on January 28, 2020 and was discharged on February 13, 2020. The comprehensive treatment plan was signed by the client on February 28, 2020.Client # 13 was admitted to the partial hospitalization program on February 6, 2020 and was discharged on February 27, 2020. The comprehensive treatment plan was signed by the client on September 27, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon resumption of the partial level of care staff will be trained on the document requirements that include a individualized treatment plan that includes type and frequency. The EHR has been configured to require this. The clinical supervisor will monitor through ongoing supervision of the staff in this level of care. |