INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 15-16, 2021 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of seven personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #2 was hired as the clinical supervisor on December 2, 2019 and was due to have the communicable disease trainings no later than December 2, 2020. Documentation within the personnel record indicated employee #2 received the training until December 8-9, 2020 for the HIV/AIDS training and February 18, 2021 for the TB/STD training.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
1. PPI AIR program will develop HIV/AIDS training curriculum within the requirements of DDAPs approved training as noted in Alert 1-97, in order to offer it to all current and new employees. Training to be developed by 5/31/2021.
2. As of April 2021, Counselors and Counselor Assistants will be required to register for DDAP trainings within their initial 90 days of hire.
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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 fifteen patient records, the facility failed to ensure that all patients received 2.5 hours of psychotherapy per month for the first two years of treatment in eight patient records.
Patient #2 was admitted on January 26, 2021 and was still active at the time of the inspection. In February 2021, the patient received 0 hours of psychotherapy.
Patient #7 was admitted on October 11, 2019 and was discharged on July 1, 2020. The client received 0 hours of psychotherapy for the months of April, May, and June 2020.
Patient #9 was admitted on June 5, 2020 and was still active at the time of the inspection. The client has not received any psychotherapy hours since October 2020.
Patient #10 was admitted on November 11, 2020 and was still active at the time of the inspection. In January 2021 the patient only received 1.5 hours of psychotherapy and in February 2021 the patient only received 1 hour of psychotherapy.
Patient #11 was admitted on August 5, 2020 and was still active at the time of the inspection. In November 2020 the patient received 1 hour of psychotherapy, in December 2020 the patient received 0 hours of psychotherapy, in January 2021 the patient received 0 hours of psychotherapy and in February 2021 the patient received 1 hour of psychotherapy.
Patient #12 was admitted on December 2, 2020 and was still active at the time of the inspection. In December 2020, the patient received 0 hours of psychotherapy, in January 2021 the patient received 0 hours of psychotherapy and in February 2021 the patient only received 1 hour of psychotherapy.
Patient #13 was admitted on January 18, 2019 and was discharge on February 19, 202. The patient received 0 hours of psychotherapy from May 2, 2020 until discharge on February 19, 2021.
Patient #14 was admitted on October 6, 2020 and was discharged on February 22, 2021. The patient received 0 hours of psychotherapy from admission until January 13, 2021.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from an inspection conducted on April 14, 2020 and January 17, 2019.
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Plan of Correction
1. Re-education and training to all clinical staff on amount of psychotherapy required based on time in treatment. Re-education to be provided to all clinical staff by 5/1/21.
2. Clinical Manager will review reports monthly during group supervision. Discussions also will occur to support the staff in patient engagement techniques (e.g., outreach call, treatment holds, etc.).
3. In-person, live group counseling sessions to be offered throughout the week starting 4/5/21, as another means to meet the required psychotherapy hours.
4. Clinical 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.
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 supervised by the Clinical Manager on a monthly basis and reported to the Service Line Director.
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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 fourteen patient records the facility 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 transferring patient.
Patient #3 was admitted on June 3, 2020 and was still active at the time of the inspection. The patient record contained no documentation of the notification.
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 nursing staff on patient transfer process and documentation. Re-education to be provided to all nursing staff by 5/1/21, and therein annually.
2. Patient #3 dosing at two MAT facilities was originally discovered by the employee responsible for the failed notification. The situation was identified and resolved prior to any facility inspections. The employee was given a written plan of correction for failure to follow existing policy.
3. Transfer Patient Checklist revised and is to be completed by a nurse for every transfer patient prior to being given first dosage (includes documentation received from transferring facility, verbal verification and email correspondence regarding date of transfer and first dosage at our facility), and is all documented in the patient's electronic chart.
4. Monitoring will be tracked through the following process:
a. Chart Audits for transfer patients will be completed monthly.
b. Monthly chart audits will be supervised by the Lead RN/Nurse Manager on a monthly basis and reported to the Service Line Director.
5. Staff deficient in this area will be identified for intensive retraining and coaching by supervisor.
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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 fourteen patient records, the facility failed to ensure that one applicable patient received an annual evaluation.
Patient #5 was admitted on July 23, 2018 and was still active at the time of the inspection. The patient record failed to contain an annual evaluation due July 23, 2020.
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 clinical staff annual evaluations. Re-education to be provided to all clinical staff by 5/1/21.
2. Client record #5 admitted on July 23, 2018 was resolved with completion of annual evaluation on 4/1/21.
3. Annual evaluations will be due to be completed on or before the anniversary date of their admission to treatment.
4. Monitoring will be tracked through the following process:
a. All active patients will be monitored on a monthly basis for completed annual evaluations.
b. Chart audit results will be reported on the monthly chart audit reports.
c. Monthly chart audits will be supervised by the Clinical Manager and reported to the Service Line Director.
5. Staff deficient in this area will be identified for intensive retraining and coaching by supervisor.
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709.92(a) 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:
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Observations
Based on a review of fourteen client records, the facility failed to ensure that all clients received a comprehensive treatment plan in two client records.
Client record #1 was admitted on September 23, 2020 and was still active at the time of the inspection.
Client record #12 was admitted on December 2, 2020 and was discharged on February 11, 2021.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from an inspection conducted on April 14, 2020.
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Plan of Correction
Re-education and training to all clinical staff on individual treatment planning timeline and requirements. Re-education to be provided to all clinical staff by 5/1/21.
2. Client record #1 admitted on September 23, 2020 was resolved on 3/29/21 with a completed treatment plan.
3. Monitoring will be tracked through the following process:
a. All active patients will be monitored on a monthly basis for completed comprehensive treatment plans.
b. Chart audit results will be reported on the monthly chart audit reports.
c. Monthly chart audits will be supervised by the Clinical Manager and reported to the Service Line Director.
4. Staff deficient in this area will be identified for intensive retraining and coaching by supervisor.
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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 fourteen client records, the facility failed to ensure that all treatment plans were updated at least every 60 days in seven client records.
Client # 3 was admitted on June 3, 2020 and was still active at the time of the inspection. A treatment plan updated was created on November 9, 2020 and an update was due no later than January 9, 2021, however no update was completed until January 20, 2021.
Client # 5 was admitted on July 23, 20218 and was still active at the time of the inspection. A treatment plan updated was created on December 17, 2020 and an update was due no later than February 17, 2021, however no update was completed until March 4, 2021.
Client # 6 was admitted on April 2, 2020 and was discharged on September 28, 2020. A treatment plan updated was created on April 6, 2020 and an update was due no later than June 6, 2020, however no update was completed until August 17, 2020.
Client # 9 was admitted on June 5, 2020 and was still active at the time of the inspection. A treatment plan updated was created on June 10, 2020 and an update was due no later than August 10, 2020, however no update was completed until October 20, 2020.
Client # 11 was admitted on August 5, 2020 and was still active at the time of the inspection. A treatment plan updated was created on November 2, 2020 and an update was due no later than January 2, 2021, however no update was completed at the time of the inspection.
Client # 13 was admitted on January 18, 2019 and was discharged on July 6, 2020. A treatment plan updated was created on October 26, 2020 and an update was due no later than December 26, 2020, however no update was completed at the time of discharge.
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 clinical staff on individual treatment planning update timelines and requirements. Re-education to be provided to all clinical staff by 5/1/21.
2. Client # 11 admitted on August 5, 2020, was resolved with completed treatment plan review and update on 4/1/21.
3. 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. Caseload review will occur at the end of the month during 1:1 supervision, to identify compliance with completion of treatment plan updates.
d. Monthly chart audits will be supervised by the Clinical Manager and reported to the Service Line Director.
4. Staff deficient in this area will be identified for intensive retraining and coaching by supervisor.
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