INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on October 27, 2022 through October 28, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, John F. Kennedy Behavioral Health Center 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 a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of eight client records reviewed.
Client # 4 was readmitted on April 19, 2022 and was still active at the time of inspection. There was a release of information form to the funding source that was signed and dated by the client on December 16, 2020 and expired on December 16, 2021. Another release of information form to the funding source was signed on October 24, 2022. There was evidence of disclosures to the funding source after the first release form expired on December 16, 2021 and prior to the new form being signed on October 24, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Every active client in treatment will meet in-person with their counselor to complete annual releases of information. Every consent form, including but not limited to: funding source; transportation agency; primary care physician; and emergency contact will contain the dated signature of the client. The Clinical Supervisor, prior to approving clinical service notes to be submitted for billing, will ensure that there is an active voluntary release of information for the funding source with a physical signature of both the client and the witness. Notes that do not comply with this procedure will be held back for submission until the person has signed the required release of information form. The Quality Assurance Officer will monitor the implementation of this procedure during compliance chart reviews. |
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 a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure is made on consent to release information forms in two of eight client records reviewed.
Client # 1 was admitted on December 6, 2021 and was still active at the time of inspection. A release of information form to a physician was signed and dated by the witness on December 17, 2021; however, the form failed to document the name of the person, agency, or organization to whom the disclosure would be made.
Client # 3 was admitted on September 17, 2019 and was still active at the time of inspection. A release of information form to a physician was signed and dated by the client on January 23, 2022; however, the form failed to document the name of the person, agency, or organization to whom the disclosure would be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Every active client in treatment will meet in-person with their counselor to complete annual releases of information upon admission and annually thereafter. Every consent form will include, but not be limited to, the name of the primary care physician to whom the disclosure is made. For those who do not have a Primary Care Physician, a notation will be made on the form with the client's signature. The Clinical Supervisor, prior to the intake physical examination and weekly via a review of counselor case management logs, will ensure that there is a fully executed voluntary release of information that clearly identifies the person's physician. Releases of information forms that do not comply with this procedure will be promptly completed within 24 hours. We are implementing an electronic monitoring/tracking system that involves staff, Clinical Supervisor, and Quality Assurance which will alert to all involved the required completion dates of the documentation. The Facility Director is responsible for this action. The releases of information for active client (Client #1) identified in the deficiency will be corrected by the Clinical Director by 12/15/2022. The Clinical Director is responsible for monitoring the completion of this task. Client #3 (previously active) has been discharged effective 11/16/2022 due to lack of attendance. Quality Assurance Officer will monitor the implementation of this procedure during compliance review of charts. |
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
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in four of eight client records reviewed.
Client # 1 was admitted on December 6, 2021 and was still active at the time of inspection. The release of information forms to the funding sources, physician, emergency contact, and transportation company were all signed and dated by the witness on December 17, 2021; however, all the forms did not include the dated signature of the client.
Client # 2 was admitted on December 14, 2021 and was still active at the time of inspection. The release of information forms to the funding sources, physician, emergency contact, and transportation company were all signed and dated by the witness on December 21, 2021; however, all the forms did not include the dated signature of the client.
Client # 5 was admitted on October 24, 2019 and was discharged on April 11, 2022. The release of information forms to the funding sources, physician, emergency contact, and transportation company were all signed and dated by the witness on November 15, 2021; however, all the forms did not include the dated signature of the client.
Client # 7 was admitted on February 11, 2022 and was discharged on September 30, 2022. The release of information forms to the funding sources, physician, emergency contact, and transportation company were all signed and dated by the witness on February 23, 2022; however, all the forms did not include the dated signature of the client.
This is a repeat citation from the November 2, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Every active client in treatment will meet in-person with their counselor to complete annual releases of information. Every consent form, including but not limited to: funding source; transportation agency; primary care physician; and emergency contact will contain the dated signature of the client and the witness. In the Electronic Medical Record, a notification will be entered into each client's chart to provide the therapist and supervisor with a visual reminder of the due date for the annual releases. The Clinical Supervisor will review client records on a regular basis during individual supervision to ensure that all informed and voluntary release of information forms are signed and dated by the client. The Clinical Supervisor will monitor the completion of the annual consent packet two months prior to expiration date recorded in the Electronic Medical Record in order to ensure full compliance with the regulatory requirements. We are implementing an electronic monitoring/tracking system that involves staff, Clinical Supervisor, and Quality Assurance which will alert to all involved the required completion dates of the documentation. The Facility Director is responsible for this action. The releases of information for funding sources, physician, emergency contact, and transportation company will be completed, signed, and dated with the active clients noted in the deficiency (Client #1, Client #2) by the Clinical Director by 12/15/2022. The Clinical Director is responsible for monitoring the completion of this task. Quality Assurance Officer will monitor the completion and compliance of this practice during chart reviews. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in two of five applicable patient records reviewed.
Patient # 2 was admitted on December 14, 2021 and was active at the time of inspection. The record of service and progress notes documented that there was 1 hour of psychotherapy provided to the patient for the month of July 2022.
Patient # 7 was admitted on February 11, 2022 and was discharged on September 30, 2022. The record of service and progress notes documented that there was 2 hours of psychotherapy provided to the patient for the month of June 2022.
This is a repeat citation from the November 2, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients who are active in treatment will receive a minimum of 2.5 hours of psychotherapy per month. Clients who are 'active' in treatment but absent from treatment for at least 10 days will be terminated, unless they are in the hospital or a nursing home facility. The Nursing Supervisor will provide the Clinical Supervisor with a weekly list of clients 'active' but absent from treatment. These records will be properly discharged with follow-up. The Clinical Supervisor will also provide persons who may attempt to 'avoid' their counseling responsibility with advance notice of possible termination due to lack of counseling attendance. Counselors will also track hours of counseling attendance on their case management log, which will be regularly reviewed in individual supervision by the Clinical Supervisor. The Quality Assurance Officer will monitor the completion and compliance of this practice during chart reviews. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of the facility's November 2021 through October 2022 unusual incident logs, the facility failed to notify the Department within 48 hours of the offsite death of an active patient when the facility was made aware on December 17, 2021.
This finding was reviewed with project and facility staff during the licensing process.
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Plan of Correction
JFK will file a written unusual incident report with the Department of Drug and Alcohol Programs within 48 hours following an unusual incident involving but not limited to death, or serious injury due to trauma, suicide, medication error or unusual circumstances. The Clinical Supervisor will prepare the unusual incident report and will upload the report to DDAP's Unusual Incident Reporting and Electronic Reporting System (ERS). The Clinical Supervisor will also provide a copy of the submitted unusual incident report to Quality Assurance for additional monitoring for the submission of the form. |
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
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in five of eight client records reviewed.
Client # 1 was admitted on December 6, 2021 and was still active at the time of inspection. A treatment plan update was completed on February 18, 2022, and the next update was due no later than April 18, 2022; however, the update was not completed until May 2, 2022.
Client # 2 was admitted on December 14, 2021 and was still active at the time of inspection. A treatment plan update was completed on May 19, 2022, and the next update was due no later than July 19, 2022; however, the update was not completed until August 3, 2022.
Client # 3 was admitted on September 17, 2019 and was still active at the time of inspection. A treatment plan update was completed on January 31, 2022, and the next update was due no later than March 31, 2022; however, the update was not completed until July 13, 2022. Additionally, the next treatment plan update was due no later than September 13, 2022; however, the update was not completed until October 11, 2022.
Client # 4 was readmitted on April 19, 2022 and was still active at the time of inspection. The comprehensive treatment plan was completed on April 19, 2022, and an update was due no later than June 19, 2022; however, the update was not completed until July 19, 2022. Additionally, the next treatment plan update was due no later than September 19, 2022; however, the update was not completed until October 10, 2022.
Client # 8 was admitted on June 9, 2021 and was discharged on August 23, 2022. A treatment plan update was completed on February 1, 2022, and the next update was due no later than April 1, 2022; however, the update was not completed until May 10, 2022.
This is a repeat citation from the November 2, 2021, October 17, 2019 and October 4, 2018 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients who are active in treatment will have their treatment plans reviewed and updated at least every 60 days. Clients who are 'active' in treatment but absent from treatment for at least 10 days will be terminated, unless they are in the hospital or a nursing home facility. In supervision, the Clinical Supervisor will perform weekly reviews of counselor case management logs to identify required upcoming treatment plans. Counselors will be instructed to complete these treatment plan updates prior to expiration. This list will be reviewed again at the following supervisory session to ensure completion of the updates. Compliance with timely completion of treatment plans will be a topic of each weekly staff meeting. The Quality Assurance Officer will monitor the completion and compliance of this practice during chart reviews. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in two of four applicable client records reviewed.
Client # 6 was admitted on January 14, 2019 and was discharged on January 11, 2022. There was no follow up information documented in the record at the time of the inspection.
Client # 7 was admitted on February 11, 2022 and was discharged on September 30, 2022. There was no follow up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will provide Counselor training on documenting client follow-up along with discharge documentation. Each time the Clinical Supervisor reviews a person's discharged summary, a plan for client follow-up documentation will be put together with the counselor. The Discharge summary will not be approved by the Clinical Supervisor until sufficient documentation exists to show that all required follow-up procedures have been adhered to. The Quality Assurance Officer will monitor the completion and compliance of this practice during chart reviews. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative documents, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for late treatment plan updates was submitted and approved by the Department for the November 2, 2021, October 17, 2019 and October 4, 2018 annual licensing inspections. Late treatment plan updates were again found to be a deficiency in the October 27, 2022 through October 28, 2022 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Quality Assurance Officer and Facility Director will conduct a bimonthly review of a random sample of charts. In this review, all Plan of Corrections from the previous citations will be the focus of the review. If problems are found and can be corrected, they will be. If corrections cannot be made, it will be noted in the chart. If repeated issues continue counseling and progressive discipline will occur with the staff member. This is the responsibility of the Clinical Supervisor and the HR Officer. |