INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on January 25, 2022, 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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704.11(f)(1) LICENSURE Counselor's Trng Req
704.11. Staff development program.
(f) Training requirements for counselors.
(1) Subject areas for training shall be selected according to the training plan for each individual.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and five personnel records, the facility failed to document the completion of 25 clock hours of annual training required for one counselor in the personnel record.
Employee #5 was hired as a counselor on October 5, 2020 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 2021 thru December 2021. Employee #5's employee record only documented 9 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Re-education and training to all counseling staff on annual training requirements occurred on 2/23/22.
2. All counseling staff to complete 20 credit hours through Addiction Counselor CE (online training, will be purchased by program), annually.
3. All counseling staff to complete an additional 5 credit hours through PPI On-site trainings, annually.
4. Clinical Manager responsible to monitor quarterly for progress towards completion of 25 hours of training for all counseling staff.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drills from January 2021 thru December 2021, the facility failed to document on the fire drill record the exit route used in fire drills conducted in April 2021 and May 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
1. Form edited on 2/22/22 to be more user-friendly and prompt for sections that need to be completed.
2. Monitoring will be tracked through the following process:
a. PPI Safety Officer and Compliance Director are responsible to complete monthly auditing of all Fire Drill Forms.
b. All incomplete forms will be corrected within the fire drill month.
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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
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one client record that included the specific information disclosed.
Client record #1 was admitted on April 4, 2021 and was still active at the time of the inspection. A consent to release form was signed and dated on October 13, 2021, to an outside provider that failed to include the specific information to be disclosed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
1. Patient #1, still active in treatment, was resolved on 2/16/22 with a new and complete consent for release of information.
2. Re-education and training to all program staff on confidentiality policy and how to complete an consent for release of information (ROI) to it's entirety to be completed by 3/3/22.
3. Form edited on 2/18/22 to be more user-friendly and prompt for sections that need to be completed.
4. Monitoring will be tracked through the following process:
c. Clinical Manager responsible to ensure chart audits are completed monthly.
d. All non-compliance will be corrected within the chart audit month.
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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 a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include documentation that a copy of the consent was offered to the client in one record reviewed.
Client record #1 was admitted on April 4, 2021 and was still active at the time of the inspection. A consent to release form was signed and dated on October 13, 2021, to an outside provider that failed document if the client was offered a copy.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
1. Patient #1, still active in treatment, was resolved on 2/16/22 with a new and complete consent for release of information.
2. Re-education and training to all program staff on confidentiality policy and how to complete an consent for release of information (ROI) to it's entirety to be completed by 3/3/22.
3. Form edited on 2/18/22 to be more user-friendly and prompt for sections that need to be completed.
4. Monitoring will be tracked through the following process:
a. Clinical Manager responsible to ensure chart audits are completed monthly.
b. All non-compliance will be corrected within the chart audit month.
c. Monthly chart audits will be reviewed on a quarterly basis by the Management team and reported to the Service Line Director.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of seven patient records, the facility failed to ensure that patients received random urinalysis at least monthly in two applicable patient records reviewed.
Patient # 2 was admitted on March 5, 2021 and was an active patient at the time of the inspection. Urine drug screens were not completed and documented for the month of August 2021.
Patient #6 was admitted on July 6, 2021 and discharged on January 4, 2022. A urine drug screen was not completed and documented for the month of September 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. All new patients will provide a urinalysis upon admission and be informed of the monthly requirement.
2. Coordinated with our Electronic Health Record system (SAMMS) to have all patients scheduled to provide a random urinalysis within the first 20 days of each month. A hold is placed on each patient chart automatically through SAMMS to alert when a urinalysis is due.
3. Nursing staff will monitor and track urinalysis completion and compliance on a weekly basis.
4. After the 20th of each month a "Stop Dosing" hold will be placed on all patients who have not yet provided the required urinalysis.
5. Nurse Manager responsible for ensuring corrective action plan is implemented, and to monitor urinalysis completion and compliance. |
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 seven patient records, the facility failed to provide two patients with 2.5 hours of psychotherapy per month during the patient ' s first 2 years of treatment.
Patient # 1 was admitted on April 4, 2021 and was still active at the time of the inspection. In September 2021 the patient only had 2 hours of individual psychotherapy. In November 2021, the patient only had 60 minutes of psychotherapy and in December 2021, the patient only had 2 hours of psychotherapy.
Patient #2 was admitted on March 5, 2021 and was still active at the time of the inspection. In September 2021 the patient only had 80 minutes of psychotherapy hours. In October 2021, the patient only had 30 minutes of psychotherapy. In November the patient only had 60 minutes of psychotherapy and no hours in December 2021.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from inspections conducted on March 16, 2021, February 27, 2020, and January 17, 2019.
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Plan of Correction
1. Re-education and training to all counseling staff on amount of psychotherapy required based on time in treatment occurred on 2/23/22.
2. Clinical Manager will review reports monthly during group supervision for patients whom have not completed the required psychotherapy hours for the month. Discussions also will occur to support the staff in patient engagement techniques (e.g., outreach call, treatment holds, etc.).
3. Counseling staff will update patient treatment plans to reflect the amount of required psychotherapy per month, as well as progress or lack of progress of compliance with the required psychotherapy hours per month.
4. Counseling staff will utilize stop dose holds, warning letters, and treatment agreements to address patient non-compliance with meeting the required psychotherapy hours.
5. All no-shows, rescheduled appointments, or cancellations will be documented in the electronic health record system.
6. Monitoring will be tracked through the following process:
a. Chart Audits for patient compliance will be completed monthly.
b. All non-compliance will be documented and addressed on the treatment plan or treatment plan update.
c. Monthly chart audits will be reviewed on a quarterly basis by the Management team and reported to the Service Line Director.
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715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of seven patient records, the facility failed to provide one patient with 1 hour of psychotherapy per month during the patient ' s third and fourth years of treatment.
Patient # 4 was admitted on August 5, 2019 and was still active at the time of the inspection. The patient received no hours of psychotherapy during the months of September, October, November, and December 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
1. Re-education and training to all counseling staff on amount of psychotherapy required based on time in treatment occurred on 2/23/22.
2. Clinical Manager will review reports monthly during group supervision for patients whom have not completed the required psychotherapy hours for the month. Discussions also will occur to support the staff in patient engagement techniques (e.g., outreach call, treatment holds, etc.).
3. Counseling staff will update patient treatment plans to reflect the amount of required psychotherapy per month, as well as progress or lack of progress of compliance with the required psychotherapy hours per month.
4. Counseling staff will utilize stop dose holds, warning letters, and treatment agreements to address patient non-compliance with meeting the required psychotherapy hours.
5. All no-shows, rescheduled appointments, or cancellations will be documented in the electronic health record system.
6. Monitoring will be tracked through the following process:
a. Chart Audits for patient compliance will be completed monthly.
b. All non-compliance will be documented and addressed on the treatment plan or treatment plan update.
c. Monthly chart audits will be reviewed on a quarterly basis by the Management team and reported to the Service Line Director.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of seven patient records, the facility failed to document an annual physical examination of the patient in one patient record reviewed.
Patient #4 was admitted on August 5, 2019 and was still active at the time of the inspection. The most recent annual physical evaluation was due no later than August 5, 2021; however, it was not documented 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
1. Patient #4, still active in treatment, was resolved with an Annual Physical examination scheduled for 2/28/22.
2. Physical exams for all new patients will be completed on admission and re-assessment scheduled at the time of admission for approximately 11 months later.
3. A "Stop Dosing" hold will be placed on all patients at 11 months until they complete their physical exam.
4. Monitoring will be tracked through the following process:
a. Chart review for all new patients will be completed monthly by nursing staff, to ensure that the patient has been scheduled for a follow-up at 11 months for their Annual Physical.
b. All non-compliance will be corrected at the time it is discovered, by patient getting scheduled for Annual Physical at the 11-month mark.
c. Nurse Manager responsible to ensure corrective action plan is implemented and chart reviews are completed monthly.
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715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
Based on a review of the facility ' s policy and procedure manual and seven patient records, the facility failed to complete and document at least one case consultation a year in two patient records reviewed.
Patient #4 was admitted August 5, 2019 and still active at the time of the inspection. The patient record did not contain documentation of a case consultation.
Patient #7 was admitted on August 5, 2019 and discharged on April 12, 2021. The patient record did not contain documentation of a case consultation.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
1. Patient #4, still active in treatment, was resolved on 2/3/22, with completion of a Case Consultation Form documented.
2. Re-education and training to all counseling staff on Case Consultation requirements occurred on 2/23/22.
3. Case Consultation forms to be completed by counselor for every case discussed at Multi-disciplinary treatment team meetings and within Clinical Supervision.
4. Case Consultation forms will be due to be completed on or before their anniversary date of their admission to treatment.
5. Monitoring will be tracked through the following process:
a. Chart Audits for completion will be completed monthly.
b. All non-compliance will be documented and resolved during that month.
c. Monthly chart audits will be reviewed on a quarterly basis by the Management team and reported to the Service Line Director.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of seven patient records, the facility failed to document an annual clinical evaluation of the patient in two patient records.
Patient #4 was admitted on August 5, 2019 and was still active at the time of the inspection. The most recent annual evaluation was due no later than August 5, 2021; however, it was not documented as of the date of the inspection.
Patient #7 was admitted on August 5, 2019 and was discharged on April 13, 2021. The most recent annual evaluation was due no later than August 5, 2021; however, it was not documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from an inspection conducted on March 16, 2021.
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Plan of Correction
1. Patient #4, still active in treatment, was resolved on 1/25/22, with completion of an Annual Clinical Evaluation documented.
2. Re-education and training to all counseling staff on Annual Evaluation requirements occurred on 2/23/22.
3. Annual Clinical Evaluation forms will be due to be completed by the counselor on or before their anniversary date of their admission to treatment.
4. Monitoring will be tracked through the following process:
a. Clinical Manager will ensure chart Audits will be completed monthly.
b. All non-compliance will be documented and resolved during that month.
c. Monthly chart audits will be reviewed on a quarterly basis by the Management team and reported to the Service Line Director.
d. Clinical Manager responsible for ensuring corrective action plan is implemented and monthly monitoring is completed.
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715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of seven patient records, the facility failed to document treatment plan updates within the regulatory timeframe in six patient records reviewed.
Patient #1 was admitted on April 8, 2021 and was still active at the time of the inspection. A treatment plan update was completed on November 10, 2021 and the next update was due no later than January 10, 2022; however, there was no update documented in the record at the time of the inspection.
Patient #2 was admitted on March 5, 2021 and was still active at the time of the inspection. A treatment plan update was completed September 9, 2021 and the next update was due no later than November 9, 2021; however, there was no update documented in the record at the time of the inspection.
Patient #3 was admitted on April 14, 2021 and was still active at the time of the inspection. A treatment plan updated was completed on August 9, 2021 and the next update was due no later than October 9, 2021; however, there was no update documented in the record at the time of the inspection.
Patient #4 was admitted on August 5, 2019 and was still active at the time of the inspection. A treatment plan update was completed April 27, 2019. At the time of the inspection no treatment plan updates documented in the patient record.
Patient #5 was admitted on July 6, 2021 and was discharged on January 4, 2022. A treatment plan update was completed on October 18, 2021 and the next update was due no later than December 18, 2021; however there was no update documented in the record at the time of the inspection.
Patient #6 was admitted on August 5, 2019 and was discharged on April 13, 2021. A treatment plan updated was completed on October 7, 2020 and the next update was due no later than December 7, 2020; however there was no update documented in the record at the time of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
1. Patient #1, still active in treatment, was resolved on 1/26/22, with an updated treatment plan.
2. Patient #2, still active in treatment, was resolved on 2/18/22, with an updated treatment plan.
3. Patient #3, still active in treatment, was resolved on 2/18/22, with an updated treatment plan.
4. Patient #4, still active in treatment, was resolved on 1/25/22, with an updated treatment plan.
5. Re-education and training to all counseling staff on treatment planning timeline and requirements occurred on 2/23/22.
6. Monitoring will be tracked through the following process:
a. All active patients will be monitored on a monthly basis for completed comprehensive treatment plan review/updates.
b. Caseload review will occur at the beginning of every month during 1:1 supervision, to identify what treatment plan updates are due for upcoming month.
c. Automatic alerts/holds will be utilized in our EHR system to also alert of when treatment plan updates are due.
d. Caseload review will occur at the end of the month during 1:1 supervision, to identify compliance with completion of treatment plan updates.
e. Monthly chart audits will be supervised by the Clinical Manager and reported to the Service Line Director.
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709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of seven patient records and the facility ' s policy and procedure manual. The facility failed to complete comprehensive treatment plans within 30 days in five of seven records reviewed.
Patient #1 was admitted on April 8, 2021 and was still active at the time of the inspection. The patient ' s comprehensive treatment plan was not completed until September 23, 2021.
Patient #2 was admitted on March 5, 2021 and was still active at the time of the inspection. The patient ' s comprehensive treatment plan was not completed until June 24, 2021.
Patient #3 was admitted on April 14, 2021 and was still active at the time of the inspection. The patient ' s comprehensive treatment plan was not completed until August 9, 2021.
Patient #5 was admitted on March 5, 2021 and was discharged on May 10, 2021. The patient ' s record did not contain a comprehensive treatment plan at the time of the inspection.
Patient #6 was admitted on July 6, 2021 and was discharged on January 4, 2022. The patient ' s comprehensive treatment plan was not completed until August 13, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
1. Re-education and training to all counseling staff on Initial Comprehensive Treatment Planning and timeline requirements occurred on 2/23/22.
2. Process update- Initial Comprehensive Treatment Plan to be completed during the Clinical Intake session, to ensure compliance with completing in 30 days from admission.
3. Monitoring will be tracked through the following process:
a. Chart Audits for completion will be completed monthly.
b. All non-compliance will be documented and resolved during that month.
c. Monthly chart audits will be reviewed on a quarterly basis by the Management team and reported to the Service Line Director.
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