INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on August 27, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site investigation, 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 investigation:
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Plan of Correction
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
The facility failed to keep the grounds of the facility clean, safe, and sanitary at all times for the safety and well-being of clients, employees and visitors.
During an onsite complaint investigation conducted on August 27, 2026, the water dispenser in the lobby was observed to have a chalky mineral deposit on the surface of the tray and running down the outside of the water dispenser.
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Plan of Correction
1) Water Cooler was replaced with new model.
2) Clean-up/ maintenance of water cooler is added to weekly environmental walk-through.
3) Clinical Manager is responsible for weekly environmental walk-through, and surface cleaning, as needed.
4) Any ongoing maintenance issues with the water cooler will be discussed with the vendor for water cooler replacement, as needed.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of patient records and the Methadone Induction and Re-Induction policy, the facility failed to follow its written procedures for the management of treatment services for patients in two of two applicable records reviewed.
Per the Methadone Induction and Re-Induction policy, the following steps must occur for patients who have not received their dose of methadone for between 3-14 days. Dispensing nurse: inquire about the reason for missed doses and document this reason in the patient record. Facilitate a point of care urine drug test and document the results of the UDS in the patient record. Communicate with physician the reasons for missed doses, and the results of the urine drug test, and this conversation needs to be documented in the patient record.
Patient # 2 was admitted on March 17, 2026, and was still an active patient at the time of this investigation. This patient did not receive their dose of methadone for 5 days and was placed on a re-induction. There was no documentation from the dispensing nurse regarding the reason for missed doses nor of the conversation between the nurse and physician.
Patient # 4 was admitted on October 24, 2024, and was still an active patient at the time of this investigation. This patient did not receive their dose of methadone for 5 days and was placed on a re-induction. There was no documentation from the dispensing nurse regarding the reason for missed doses nor of the conversation between the nurse and physician. There was also no documentation of a urine drug test being facilitated at the time of re-induction.
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Plan of Correction
1. Staff training occurred on 9/1/26: new procedure for re-inductions, to include updated documentation, urine drug test, and communication with physician.
2. Re-Induction Service Note has been created and added to the electronic charting system, to capture all areas required to be documented.
3. Monthly random chart audits will be done for re-induction patients to monitor procedure being followed, and documentation being completed correctly. Clinical Manager responsible for this task. Findings will be shared with Lead RN, and follow-up will be done as needed for corrections.
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