INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring , inspection conducted on February 26-27, 2020 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, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, it was discovered that that Employee #7, whom was hired as a counselor on February 3, 2020 did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1.Employee #7 resolved. Staff in question moved officially moved to Counselor Assistant position on April 27, 2020.
2.As of March 2020, qualifications for all potential new hires will be reviewed and verified by Human Resources prior to offer letters being given.
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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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #3, #9 and ##10 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 #3 was hired as a counselor on November 5, 2018 and was due to have the communicable disease trainings no later than November 5, 2019. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #9 was hired as administrative staff on January 8, 2018 and was due to have the communicable disease trainings no later than January 8, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #10 was hired as an Office Manager on August 28, 2017 and was due to have the communicable disease trainings no later than August 28, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
These Findings were discussed with Facility Staff during the inspection process.
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Plan of Correction
1.Employee #3 will be scheduled for the next available TB/STD training. Target date 3-6 months with all current state education offerings on hold.
2.Staff # 9 has been employed by PPI since 01/18/2018 but was transferred to the OTP on 01/20/2019. Staff #9 will complete the 6 hours of HIV/AIDS training and at least 4 hours of TB/STD by 01/20/2021.
3.Staff # 10 has been employed by PPI since 08/28/2017 but was transferred to the OTP on 12/24/2018. Staff #10 will complete the 6 hours of HIV/AIDS training and at least 4 hours of TB/STD by 12/24/2020.
4.All OTP new hires will be scheduled will be registered for HIV/AIDs and TB/STD training through DDAP's website within their first 30 days.
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a discussion with Facility Staff the facility failed to create and make public an annual report for the fiscal year of July 2018-June 2019. The last annual report by the facility was created for July 2017-June 2018
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Pennsylvania Psychiatric Institute will public a subsection for the OTP to be included as part of PPI's annual report made available to the public. Target date for completion of the annual report is August 2020 to reflect FY20. |
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 the review of thirteen client records, the facility failed to document a completed consent to release information in five records, as there were forms that were missing required information.
Client #7 was admitted on November 27, 2018 and was discharged on February 12, 2020 . There was a consent to release forms , signed and dated on February 6, 2020 an emergancy contact, Quest Labs, and funding source that failed to document if the client was offered a copy of the release.
Client #8 was admitted on July 17, 2018 and was discharged on January 2, 2020. There was a consent to release forms signed and dated on May 28, 2019 to an emergancy contact, Quest Labs, and funding source that failed to document if the client was offered a copy of the release.
Client #9 was admitted on April 2, 2019 and was still active at the time of inspection. There was a consent to release forms , signed and dated on February 17, 2020 an emergancy contact, Quest Labs, and funding source that failed to document if the client was offered a copy of the release.
Client #10 was admitted on September 4, 2019 and was still active at the time of inspection . There was a consent to release forms , signed and dated on September 4, 2019 an emergancy contact, Quest Labs, and funding source that failed to document if the client was offered a copy of the release.
Client #11 was admitted on August 28, 2018 and was still active at the time of inspection . There was a consent to release forms , signed and dated on February 12, 2020 an emergancy contact, Quest Labs, and funding source that failed to document if the client was offered a copy of the release.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
1.Re-education/training to all staff on completion of consent forms. Re-education provided to all staff by 05/15/2020.
2.Client #7 and Client # 8 unable to be resolved due to discharge status.
3.Client #9 signed new consents that included an indication that the client was offered a copy of the release on 04/28/2020.
4.Client #10 will sign new consents that include an indication that the client was offered a copy of the release on next in-person visit targeted to be completed at the next in-live session. Currently, patient is engaged in Telehealth services and a non-NTP patient.
5. Client #11 will sign new consents that include an indication that the client was offered a copy of the release on next in-person visit. Currently, patient is engaged in Telehealth services and a non-NTP patient.
6.Monitoring will be tracked through the following process:
a.Chart Audits will be completed weekly to track this documentation component.
b.Chart audit results will be reported at weekly staff meeting and or individual supervision meetings until the set baseline of 100% is reached for four (4) consecutive weeks.
c.Once the threshold baseline of 100% is reached for four (4) consecutive weeks, the indicator will be added to the monthly chart auditing process.
d.Monthly chart audits will be supervised by the Clinical Manager and reported to the Service Line Director.
7.Staff deficiencies in this area will follow the Human Resource policies and processes elated to staff performance issues.
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709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develope a procedure to respond to the unusual incident of physical assault or sexual assault by staff or a client.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
1. Revisions and changes to Policy # AIR 1.70: Critical and Unusual Incident Reporting to the Department of Drug and Alcohol Programs (DDAP) to meet both § 709.34. Reporting of unusual incidents. Freestanding Drug and Alcohol Treatment Facilities (i.e., non-Narcotic Treatment Programs). § 715.28. Unusual incidents reporting for Narcotic Treatment Programs (NTPs) for reporting (1) Physical assault or sexual assault by staff or a client.
2. Policy changes and revisions to be approved by PPI's governing body May 29th 2020.
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709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develope a procedure to respond to the unusual incident of Selling or use of illicit drugs on the premises.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
1. Revisions and changes to Policy # AIR 1.70: Critical and Unusual Incident Reporting to the Department of Drug and Alcohol Programs (DDAP) to meet both § 709.34. Reporting of unusual incidents. Freestanding Drug and Alcohol Treatment Facilities (i.e., non-Narcotic Treatment Programs). § 715.28. Unusual incidents reporting for Narcotic Treatment Programs (NTPs) for reporting Selling or use of illicit drugs on the premises.
2. Policy changes and revisions to be approved by PPI's governing body May 29th. 2020.
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709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develope a procedure to respond to the unusual incident of Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
1. Revisions and changes to Policy # AIR 1.70: Critical and Unusual Incident Reporting to the Department of Drug and Alcohol Programs (DDAP) to meet both § 709.34. Reporting of unusual incidents. Freestanding Drug and Alcohol Treatment Facilities (i.e., non-Narcotic Treatment Programs). § 715.28. Unusual incidents reporting for Narcotic Treatment Programs (NTPs) for reporting Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
2. Policy changes and revisions to be approved by PPI's governing body May 29th. 2020
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709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develope a procedure to respond to the unusual incident of Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
1. Revisions and changes to Policy # AIR 1.70: Critical and Unusual Incident Reporting to the Department of Drug and Alcohol Programs (DDAP) to meet both § 709.34. Reporting of unusual incidents. Freestanding Drug and Alcohol Treatment Facilities (i.e., non-Narcotic Treatment Programs). § 715.28. Unusual incidents reporting for Narcotic Treatment Programs (NTPs) for reporting Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
2. Policy changes and revisions to be approved by PPI's governing body May 29th. 2020.
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709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develope a procedure to respond to the unusual incident of Theft, burglary, break-in or similar incident at the facility
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
1. Revisions and changes to Policy # AIR 1.70: Critical and Unusual Incident Reporting to the Department of Drug and Alcohol Programs (DDAP) to meet both § 709.34. Reporting of unusual incidents. Freestanding Drug and Alcohol Treatment Facilities (i.e., non-Narcotic Treatment Programs). § 715.28. Unusual incidents reporting for Narcotic Treatment Programs (NTPs) for reporting: Theft, burglary, break-in or similar incident at the facility.
2. Policy changes and revisions to be approved by PPI's governing body May 29th. 2020.
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709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develope a procedure to respond to the unusual incident of Event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
1. Revisions and changes to Policy # AIR 1.70: Critical and Unusual Incident Reporting to the Department of Drug and Alcohol Programs (DDAP) to meet both § 709.34. Reporting of unusual incidents. Freestanding Drug and Alcohol Treatment Facilities (i.e., non-Narcotic Treatment Programs). § 715.28. Unusual incidents reporting for Narcotic Treatment Programs (NTPs) for reporting Event at the facility requiring the presence of police, fire or ambulance personnel.
2. Policy changes and revisions to be approved by PPI's governing body May 29th. 2020
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709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develope a procedure to respond to the unusual incident of Fire or structural damage to the facility.
These findings were discussed with the facility staff during the inspection process
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Plan of Correction
1.Revisions and changes to Policy # AIR 1.70: Critical and Unusual Incident Reporting to the Department of Drug and Alcohol Programs (DDAP) to meet both § 709.34. Reporting of unusual incidents. Freestanding Drug and Alcohol Treatment Facilities (i.e., non-Narcotic Treatment Programs). § 715.28. Unusual incidents reporting for Narcotic Treatment Programs (NTPs) for reporting: Fire or structural damage to the facility.
2.Policy changes and revisions to be approved by PPI's governing body May 29th. 2020.
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709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develope a procedure to respond to the unusual incident of Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification
These findings were discussed with the facility staff during the inspection process
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Plan of Correction
1.Revisions and changes to Policy # AIR 1.70: Critical and Unusual Incident Reporting to the Department of Drug and Alcohol Programs (DDAP) to meet both § 709.34. Reporting of unusual incidents. Freestanding Drug and Alcohol Treatment Facilities (i.e., non-Narcotic Treatment Programs). § 715.28. Unusual incidents reporting for Narcotic Treatment Programs (NTPs) for reporting: Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
2. Policy changes and revisions to be approved by PPI's governing body May 29th. 2020.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of thirteen client records, the facility failed to ensure that all clients sign a written consent to treatment prior to treatment in two client records.
Client #3 was admitted on January 24, 2020 and was still active at the time of inspection.
Client #4 was admitted on October 24, 2019 and was still active at the time of inspection.
These findings were discussed with facility staff.
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Plan of Correction
1.Re-education/training to all staff on completion of consent forms. Re-education provided to all staff by 05/15/2020.
2.Client #3, admitted on January 24, 2020, informed patient consent to be complete upon patient's next in-person visit.
3.Client #4, admitted October 24, 2019, informed patient consent was completed on 04/25/2020.
4.Monitoring will be tracked through the following process:
a.All new admissions for
methadone and LAAM maintenance or detoxification treatment charts to be audited for completion of Informed Patient Consent.
b.Chart audit results will be reported at both individual supervision and/or weekly group supervisions until 100% compliance is reached for four (4) consecutive weeks.
c.Once the threshold baseline of 100% is reached for four (4) consecutive weeks, the indicator will be added to the monthly chart auditing process.
d.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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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 thirteen client records, the facility failed to provide patient # ' s 5, 7, 9, 10 and 12 with 2.5 hours of psychotherapy per month during the patient ' s first 2 years of treatment.
Patient # 5 was admitted on October 7, 2019 and was still active at the time of inspection. In February 2020 , the client had 1 hour of individual therapy and 0 hours of group therapy. In January 2020, the client had 1 hour of individual therapy and 0 hours of group therapy. In December 2019, the client had 1 hour of individual therapy and 0 hours of group therapy. There was no documentation of client no shows or cancellations during those time periods.
Patient #7 was admitted on November 27, 2018 and was still ative at the time of inspection. In January 2020, the client had .86 minutes of individual therapy and 1.5 hours of group therapy. In December 2019 , the client had .86 minutes of individual therapy and 1.5 hours of group therapy. In November 2019, the client had .86 minute of individual therapy and 1.5 hours of group therapy. There was no documentation of client no shows or cancellations during those time periods.
Patient # 9 was admitted on April 2, 2019 and was still active at the time of inspection. In October, November and December 2019 the client recieved 0 hours of indivdiual and 0 hours of group therapy. There was no documentation of client no shows or cancellations during those time periods.
Patient # 10 was admitted on September 4, 2019 and was still active at the time of inspection. In September 2019, the client had .83 minutes of individual therapy and 0 hours of group therapy. In October 2019, the client had 2 hours and 16 minutes of individual therapy and 0 hours of group therapy. In November 2019, the client had 1.5 hours of individual therapy and 0 group therapy. In January 2020, the client had 2.25 hours of indivudal therapy and 0 hours of group therapy. There was no documentation of client no shows or cancellations during those time periods.
Patient # 12 was admitted on May 22, 2019 and was still active at the time of inspection.The client has had 0 hours of individual and group therapy since October 23, 2019. There was no documentation of client no shows or cancellations during those time periods.
These findings were discussed with the facility during the inspection process.
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Plan of Correction
1.Re-education/training to all staff on completion of consent forms. Re-education provided to all staff on or by 05/15/2020.
2.Electronic health record reports have been created to track patient compliance throughout each month to identify points of intervention.
3.Clinical Manager will review reports in weekly individual and group supervisions and/or team meetings and support the staff in patient engagement techniques (e.g., outreach call, treatment holds, etc.).
4.Clinical staff will update patient treatment plans to reflect progress or lack of progress of compliance with the required 2.5 hours of psychotherapy 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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715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of thirteen client records, the facility failed to ensure that all clients recieved a psychosocial evaluation.
Client #10 was admitted September 4, 2019 and was still active at the time of inspection. The client record failed to include a psychosocial evaluation.
Client #12 was admitted May 22, 2019 and was still active at the time of inspection. The client record failed to include a psychosocial evaluation.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
1.Re-education/training to all staff on completion of consent forms. Re-education provided to all staff by 05/15/2020.
2.Client #10 admitted September 4, 2019 resolved on 04/22/2020 with a completed psychosocial evaluation.
3. Client #12 admitted May 22, 2019 resolved on 04/22/2020 with a completed psychosocial evaluation.
4. Monitoring will be tracked through the following process:
a.All new admission charts to be audited for completion of psychosocial evaluation within 7 days of date of admission.
b.Chart audit results will be reported at the weekly staff meeting until 100% compliance is reached for four (4) consecutive weeks.
c.Once the threshold baseline of 100% is reached for four (4) consecutive weeks, the indicator will be added to the monthly chart auditing process.
d.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 client records, the facility failed to ensure that all clients recieved a comphrensive treatment plan in two of thirteen client records.
Client #10 was admitted on September 4, 2019 and was still active at the time of inspection. The clients record contained a blank comphrensive treatment plan dated September 24, 2019.
Client#12 was admitted on May 22, 2019 and was still active at the time of inspection. The clients record did not contain a comphrensive treatment plan.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
1.Re-education/training to all staff on completion of consent forms. Re-education provided to all staff on or by 05/15/2020.
2.Client #10 admitted on September 4, 2019 resolved on 04/22/2020 with a completed Treatment Plan.
3.Client#12 admitted on May 22, 2019 resolved on 04/27/2020 with a completed Treatment Plan.
4.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.
5.Staff deficient in this area will be identified for intensive retraining and coaching by supervisor
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