INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on January 22, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Psychiatric Institute 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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709.28 (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
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of eight records reviewed.
Client #3 was admitted on January 8, 2025 and was active at the time of the inspection. A release of information for a laboratory was signed and dated by the client on January 8, 2025. The release of information expired on January 8, 2026; however, the project made disclosures to the laboratory on January 16, 2026, without obtaining a new release of information.
Client #5 was admitted on March 7, 2025 and was discharged on July 11, 2025. The facility failed to document to obtain a release of information for the funding source, and it was verified that billing had occurred.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
1. Re-training for all staff to occur by 2/19/26. Re-training to focus on confidentiality regulations and necessity to renew consents timely.
2. Implementing daily review of consents for patients with scheduled appointments for following date, to ensure if any need updated, it is done when they arrive for services. This task to be completed by Registration staff, monitored by Office Coordinator. This effort began on 2/9/26.
3. Random Monthly Chart audits conducted by Clinical Manager will also occur for monitoring of compliance.
4. Resolved and renewed consent for Client #3 on their next visit date, 1/27/26. Unable to resolve Client #5 due to being discharged at time of finding.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosures will be made to in one of eight records reviewed.
Client #6 was admitted on July 24, 2023 and was discharged on July 28, 2025. A release of information form signed by the client on March 12, 2025, did not specify the name of the person, agency or organization to whom disclosure is to be made.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
1. Re-training for all staff to occur by 2/19/26. Re-training to focus on how to complete a consent, areas that are required to be filled out, and importance of completing a consent properly.
2. Implementing daily review of consents for patients with scheduled appointments for following date, to ensure if any need updated, it is done when they arrive for services. This task to be completed by Registration staff, monitored by Office Coordinator. This effort began on 2/9/26.
3. Random Monthly Chart audits conducted by Clinical Manager will also occur for monitoring of compliance.
4. Unable to resolve Client #6 due to being discharged at time of finding.
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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 the review of client records, the project failed to offer a copy of the release of information forms in two of eight records reviewed.
Client #3 was admitted on January 8, 2025 and was active at the time of the inspection. There was no documentation that the client was offered a copy of the release of information form for the emergency contact; signed and dated by the client on December 10, 2025.
Client #7 was admitted on July 25, 2025 and was active at the time of the inspection. There was no documentation that the client was offered a copy of the release of information form for a laboratory; signed and dated by the client on July 25, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
1. Re-training for all staff to occur by 2/19/26. Re-training to focus on how to complete a consent, areas that are required to be filled out, and importance of completing a consent properly.
2. Implementing daily review of consents for patients with scheduled appointments for following date, to ensure if any need updated, it is done when they arrive for services. This task to be completed by Registration staff, monitored by Office Coordinator. This effort began on 2/9/26.
3. Random Monthly Chart audits conducted by Clinical Manager will also occur for monitoring of compliance.
4. Resolved and renewed consent for Client #3 on their next visit date, 1/27/26. Resolved and renewed consent for Client #7 on their next visit date, 2/4/26.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the program failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program in one applicable patient records reviewed.
Patient #7 was admitted on July 25, 2025, and was a current patient at the time of the inspection. There was no documentation indicating that the program notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
1. Policy- "Patient Transfers" was revised on 2/11/26 to reflect documentation and coordination needs for all patient transfers.
2. Re-training for all nursing and management staff to occur by 2/19/26. Re-training to focus on transfer policy and regulation.
3. Transfer acknowledgement form to be completed for all transferring patients by a member of the nursing staff.
4. Notification to transferring program to be completed and documented in the patient's Electronic Medical Record (EMR).
5. Documentation of coordination with transferring program placed in Patient #7's EMR on 2/12/26. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on the review of the facility' s policy and procedure manual, the facility failed to develop a follow-up policy to include following up on all clients that had been discharged from the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Policy- "Aftercare Planning and Follow-up" was revised on 2/11/26 to reflect follow-up efforts post-discharge.
2. Policy now reflects need for counselor to follow-up with discharged patients within 60 days of discharge date. Follow-up to be completed via phone call. If there is no phone number on file in patient chart, letter to be sent to address on file. Follow-up attempts and outcomes to be documented in patient Electronic Medical Record (EMR).
3. Training for clinical staff to occur by 2/19/26. Training will focus on policy revisions, staff responsibility to complete follow-up calls, and documentation in the EMR.
4. Random Monthly Chart audits conducted by Clinical Manager will occur to monitor compliance.
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