INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and the inspection for the approval to use a narcotic agent, specifically buprenorphine, in the treatment of narcotic addiction, which was conducted on December 14, 2015 through December 16, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Penn Foundation for Mental Health, 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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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on an observation during the physical plant inspection, it was determined that the project failed to maintain all structures on the grounds of the facility so as to be free from any danger to health or safety in one of the group counseling rooms.
The findings were:
An inspection of the residential portion of the facility conducted on December 15, 2015 at approximately 1:00 pm, it was observed that in the 1st floor large group room located in the project's residential building , there were multiple ceiling tiles broken and cracked. The tile where the smoke detector was located was broken in half, which was exposing the interconnected wiring and backside of the detector, which poses a safety risk.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Inpatient Director submitted a maintenance request ticket upon discovery on 12/14/2015. The maintenance worker inspected the area. The safety risk was assessed. A new tile was installed. As part of the safety committee a facility checklist adding this concern will be added to prevent further occurrences. The safety committee will complete a bi annual completion of the facility checklist to identify tiles requiring replacement by the maintenance department. Items identified will be replaced. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on the physical plant inspection of the residential portion of the project, the project failed to maintain frozen food at or below 0 degrees fahrenheit in two of four refrigerator/freezers.
The findings include:
The physical plant inspection was conducted on December 15, 2015 at approximately 1:00 pm. A total of four refrigerator/freezers are provided for client and staff food storage.
In the staff refrigerator/freezer, located in the staff break room on the 1st floor of the residential building, the freezer temperatures were above 0F for 16 days in August 2015, 30 days in September 2015, 31 days in October 2015, 30 days in November 2015 and 15 days in December 2015.
In the client refrigerator/freezer, known as the 'Silver Refrigerator,' which is located in the kitchen area, the freezer temperatures were above 0F for 30 days in June 2015, 31 days in July 2015, 31 days in August 2015, 30 days in September 2015, 31 days in October 2015, 23 days in November 2015, and 12 days in December 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 1/6/2016, overnight staff working in the Recovery Center will notify the maintenance department any time the freezer temperature reads above 0 degrees Fahrenheit. Maintenance will check the identified freezer and will adjust the temperatures as necessary to maintain 0 degrees. In the event that the freezer cannot be maintained at or below 0 degrees maintenance staff will perform maintenance or repairs. The program director will check freezer temp logs weekly to ensure this process is being followed. Staff will be trained regarding this process at a staff meeting on 1/6/2016. |
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
Based on a review of client records, the facility failed to document a preliminary treatment and rehabilitation plan in the partial hospitalization activity in one of two client records reviewed.
The findings include:
Twenty-four client records were reviewed on December 14, 2015 through December 16, 2015. Two client records pertained to the partial hospitalization activity and both required documentation of a preliminary treatment and rehabilitation plan. The facility failed to document a preliminary treatment and rehabilitation plans in client record #24.
Client #24 was admitted into the partial hospitalization activity on October 7, 2015 and was still an active client as of the date of the on-site inspection. There was no preliminary treatment and rehabilitation plan documented in the client record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 1/05/2016, the partial hospitalization staff were re-trained by the Director of Clinical Services on the policy to complete a preliminary treatment plan upon admission. Quarterly random record audits will occur by the Director of Clinical Services to ensure preliminary treatment plan policy is being followed. |
709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on observation, the project failed to ensure that the hours of operation for their partial hospitalization activity was displayed conspicuously to the general public.
The findings include:
During the inspection of the project's outpatient/partial hospitalization center, which was conducted on December 15, 2015 at approximately 1:00 pm, it was observed that the partial hospitalization activity did not have the hours of operation posted for the public to view.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrative Assistant II has posted on the entry door to the partial project the partial hospitalization hours of activity. The facility Director is responsible to ensure the hours remain posted to ensure this deficiency will not re-occur in the future. |
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on observation, the project failed to ensure that a telephone number for their partial hospitalization activity was displayed conspicuously to the general public.
The findings include:
During the inspection of the project's outpatient/partial hospitalization center, which was conducted on December 15, 2015 at approximately 1:00 pm, it was observed that the partial hospitalization activity did not have a telephone number posted for the public to view.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrative Assistant II has posted on the entry door to the partial and outpatient projects the emergency and contact numbers for the public to view. The Facility Director will ensure the phone numbers remain posted as to not have this deficiency occur again. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observation and the physical plant inspection, the project failed to secure discharged client records within locked storage containers.
The findings include:
A physical plant inspection of the project's outpatient recovery center was conducted on December 15, 2015 at approximately 1:00 pm. At the time of the inspection, there were five filing cabinets of discharged client records located in a client-accessible hallway. Upon closer inspection, all five filing cabinets were unlocked.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 1/04/2016 the Director of Clinical Services retrained the Administrative Support Staff II in the Outpatient building on ensuring confidentiality by locking filing cabinets in between trips to the copy machine. Staff will be re-trained on a annual basis about ensuring confidentiality by the Facility Director. This will occur during a annual staff meeting. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, 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 six of twenty-four client records reviewed.
The findings included:
4 Pa. Code states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Twenty-four client records requiring proper releases of information were reviewed on December 14, 2015 through December 16, 2015. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in client record #'s 13, 18, 19, 21, 22, and 24.
Client #13 was admitted into treatment on September 11, 2015 and was discharged on October 7, 2015. A release of information form to a government agency was signed on 09/23/2015 and allowed for the disclosure of the psychiatric evaluation, treatment plan, Biopsychosocial evaluation, medications, and discharge summary, which exceeded 255.5.
Client #18 was admitted into treatment on April 23, 2015 and was discharged on June 2, 2015. There was a release of information form to a law enforcement agency dated 06/03/2015 allowing for the release of health and physical exams. Additionally, there were two separate release of information forms to two different insurance companies, one dated 04/23/2015 and the other dated 05/21/2015, both allowing for the release of the psychiatric evaluation and medications. All three release of information forms exceeded 255.5.
Client #19 was admitted into treatment on June 19, 2015 and was still an active client at the time of the inspection. A release of information to an insurance company was signed on 06/19/2015 and allowed for the disclosure of the psychiatric evaluation and medications, which exceeded 255.5.
Client #21 was admitted into treatment on May 11, 2015 and was discharged on June 4, 2015. A release of information to an insurance company was signed on 05/11/2015 and allowed for the disclosure of the psychiatric evaluation and medications, which exceeded 255.5.
Client #22 was admitted into treatment on May 22, 2015 and was discharged on July 27, 2015. A release of information to an insurance company was signed on 05/22/2015 and allowed for the disclosure of the psychiatric evaluation and medications, which exceeded 255.5.
Client #24 was admitted into treatment on October 7, 2015 and was discharged on October 19, 2015. A release of information to an insurance company was signed on 10/06/2015 and allowed for the disclosure of the psychiatric evaluation and medications, which exceeded 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 1/15/2016, counselors and behavioral health technicians will be retrained in obtaining releases of information that comply with confidentiality regulation 4 Pa, Code 255.5 regarding information released to judges, probation or parole officers, insurance companies or government officials. Staff will be retained in 4 Pa. Code 255.5 via staff meetings and/or group supervision. The program director and clinical supervisors will provide training to staff and will monitor compliance with confidentiality regulations via quarterly chart audits. All charts impacted were Inpatient charts in which the clients are no longer in service and have been discharged. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on observation, the project failed to ensure that the hours of operation for their outpatient activity was displayed conspicuously to the general public.
The findings include:
During the inspection of the project's outpatient/partial hospitalization center, which was conducted on December 15, 2015 at approximately 1:00 pm, it was observed that the outpatient activity did not have the hours of operation posted for the public to view.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrative Assistant II for Outpatient Services created a posting that was hung on the Outpatient project hours of operation posted for the public to view. The Facility director is responsible to ensure these hours remain posted to ensure not duplicating this deficiency in the future. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on observation, the project failed to ensure that a telephone number for their outpatient activity was displayed conspicuously to the general public.
The findings include:
During the inspection of the project's outpatient/partial hospitalization center, which was conducted on December 15, 2015 at approximately 1:00 pm, it was observed that the outpatient activity did not have a telephone number posted for the public to view.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrative Support staff II created a posting of both Outpatient and Partial Hospitalization project telephone contact numbers for all public to view that is entering this project. The Facility Director will ensure that the telephone numbers for the partial program remains posted in order to prevent this deficiency from re-occurring. |
709.14(b)(4) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(4) Change in activity/discontinuance of an activity.
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Observations
Based on a review of client records and a discussion with the Facility Director, the facility failed to notify the Department of a change in activity.
The findings include:
On December 14, 2015 through December 16, 2015, twenty-four client records were reviewed. The facility currently has Department approval to provide Buprenorphine in their detoxification activity, as well as having a waiver to provide outpatient maintenance. The facility documented that they were providing Buprenorphine (Suboxone) treatment services in their residential program, an activity for which they do not have Departmental authorization, in one of the twenty-four records reviewed, specifically, client records #4.
Client #4 was admitted into residential treatment on November 23, 2015 and was still an active client at the time of the inspection. The facility included documentation in the client's medical records and physician/nurse's notes which indicated that client #4 had received Suboxone treatment while in the residential level of care.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Facility Director completed the exception for Residential use of Buprenorphine utilizing the licensing alert in 4/2012. A exception with Penn Foundation board action approval was submitted to the Drug and Alcohol Licensing Department via overnight mail on 12/20/2015. The Facility Director has notified the Inpatient Director and Intake Coordinator along with Medical staff and nursing that until further information from the licensing board no further clients may be on maintenance Buprenorphine on the Residential unit. |