INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 6, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Penndel Health Mental 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to ensure all staff were instructed in the use of the fire extinguisher upon staff employment in five of five personnel records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All current staff were trained on 7/7/2023 in the use and location of fire extinguishers via OSHA qualified Fire Safety video and instruction by Director. Moving forward, each new staff member will be trained in the aforementioned manner within 1 week of date of hire. The training is to be documented via attestation signed by staff and included in personnel files. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's May 2022 through June 2023 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.
The facility's hours of operation are Monday through Thursday 8:00AM - 8:00PM and Friday 8:00AM - 4:00PM. None of the fire drills completed were conducted during the facility's afternoon and evening hours of operation.
This finding was reviewed with facility staff during the licensing process
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Plan of Correction
Facilities Director will begin to conduct fire drills throughout the hours of operation and continue to record drills in the fire drill log.
Director and associative executive director will review fire drill log on a monthly basis to ensure the drills are taking place throughout the hours of operation. If these are not being done in an appropriate manner, said directors will meet with the facilities director to address and correct issue. |
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 obtain an informed and voluntary consent form from the client for the disclosure of information contained in the client record in one of seven records reviewed.
Client #2 was admitted on March 16, 2023 and was active at the time of inspection. There was documentation of billing to the funding source; however, there was no consent form documented in the record prior to the disclosure of information.
This is a repeat citation from the May 24, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff have been informed to obtain signed release for insurance/funding purposes upon admission.
Director will review new admissions during the monthly chart audit process to ensure completion.
Client #2 is due to come into facility to correct deficiency on 7/21/2023 |
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 client records, the facility failed to document the specific information to be disclosed on a consent form in one of seven client records reviewed.
Client #1 was admitted on February 9, 2023 and was active at the time of inspection. A release of information form to an emergency contact, signed and dated by the client on March 9, 2023, did not include the specific information to be disclosed.
This is a repeat citation from the May 24, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff have been re-trained to utilize General Authorization for Release of Information, which includes the five allowable areas of disclosure, for emergency contact purposes. The client # 1 chart emergency contact is projected to be completed at next scheduled appointment 7/20/2023. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of a disclosure on consent forms in three of seven client records reviewed.
Client #1 was admitted on February 9, 2023 and was active at the time of inspection. Release of information forms to an emergency contact and a funding source, signed and dated by the client on March 9, 2023 and February 3, 2023, did not include the purpose of the disclosures.
Client #4 was admitted on May 10, 2023 and was discharged on May 30, 2023. A release of information form to a funding source, signed and dated by the client on May 10, 2023, did not include the purpose of the disclosure.
Client #7 was admitted on January 16, 2023 and was discharged on May 25, 2023. A release of information form to a funding source, signed and dated by the client on January 16, 2023, did not include the purpose of the disclosure.
This is a repeat citation from the May 24, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The purpose of the insurance release has been added as a required field and it shows on the printed version as of 7/13/2023
Regarding emergency contact release without purpose, please refer to citation related to the use of the general authorization and not the specific emergency contact release moving forward. |
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 client records, the facility failed to ensure that a copy of a client consent to release information form was offered to the client in two of seven client records reviewed.
Client #1 was admitted on February 9, 2023 and was active at the time of inspection. Release of information forms to a funding source and an emergency contact were signed and dated by the client on February 3, 2023 and March 9, 2023. There was no documentation in the record that a copy of either release of information form was offered to the client.
Client #7 was admitted on January 16, 2023 and was discharged on May 25, 2023. A release of information form to a funding source was signed and dated by the client on January 16, 2023. There was no documentation in the record that a copy of the release of information form was offered to the client.
This is a repeat citation from the July 28, 2021 and May 24, 2022 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff has been re-trained on the need to select ACCEPTED or REJECTED on each consent form. Moreover, this has now been changed to a required field, which will preclude the user from saving the form in the electronic health record without a selection being made. This change was implemented on 7/7/2023. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of a client's death or serious injury due to trauma, suicide, medication error or unusual circumstances.
On April 20, 2023, the facility was notified of the off-site death of a client. The incident was not reported to the Department until April 27, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
This issue was due to a change in the director with the current director not having access to DDAP portal. This issue was corrected with DDAP as of 4/27/2023. Email support of this director's exchanges with DDAP support to gain access will be sent to licensing specialist. Initial contact via email was made with DDAP support on 4/21/2023. The agency will continue to submit UIRs in a timely manner in accordance with DDAP regulations. Moreover, the agency has securely stored the DDAP portal login information in a centralized location to avoid this type of issue with any future change in directorship. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services the client is to receive on the client's individual treatment plan in seven of seven client records reviewed.
This is a repeat citation from the May 24, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/10/2023, all staff have been trained to include type and frequency to all treatment plans moving forward. Each client currently active in the program will have a new treatment plan created to include type and frequency regardless of current treatment plan cycle. The director will be reviewing each treatment plan upon completion to assure inclusion of type and frequency. The current workflow includes staff submitting all treatment plans to director for signature. |
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 ensure that treatment plans were reviewed and updated at least every 60 days in three of five applicable client records reviewed.
Client #1 was admitted on February 9, 2023 and was active at the time of inspection. A treatment plan update was completed on April 20, 2023 and the next update was due no later than June 30, 2023. However, the update was not completed at the time of inspection.
Client #2 was admitted on March 16, 2023 and was active at the time of inspection. The comprehensive treatment plan was completed on March 23, 2023 and the first update was due no later than May 23, 2023. However, the update was not completed at the time of inspection.
Client #5 was admitted on December 29, 2022 and was discharged on June 21, 2023. A treatment plan update was completed on April 11, 2023 and the next update was due no later than June 11, 2023. However, the update was not completed prior to the client's discharge.
This is a repeat citation from the May 24, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/10/2023, all staff have been retrained to complete treatment plans for each client at least every 60 days. The therapists were following mental health regulations not DDAP due to a recent transition to the drug and alcohol program at Penndel. Moreover, staff had only been completing treatment plans in the presence of the client, which caused the completion to fall outside of the 60 day cycle. Moving forward, staff will complete treatment plans within 60 days regardless of attendance patterns of clients.
Client #1 and #2 updated treatment plan completed 7/7/2023
Director will monitor treatment plan completion via monthly randomized chart audits. |
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 maintain a complete client record, which is to include follow-up information, in one of two applicable client records reviewed.
Client #4 was admitted on May 10, 2023 and was discharged on May 30, 2023. There was no follow-up information documented in the record as of the date of the inspection.
This is a repeat citation from the July 28, 2021 and May 24, 2022 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/10/2023, all staff have been trained to send a follow up letter at 30 days to each unsuccessful discharge to the last known address on file. Agency updated the follow up policy on 7/6/2023 to indicate that only unsuccessful discharges will receive follow up. Director will complete 30 day follow up chart reviews on all unsuccessfully discharged clients to ensure follow up outreach has been completed. |
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 client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for ensuring the client is offered a copy of a consent to release information form were submitted and approved by the Department for the May 24, 2022 and July 28, 2021 annual licensing inspections. Documentation that a copy of consent to release information forms were offered to the client was again found to be a deficiency in the July 6, 2023 licensing inspection.
Plans of correction for document follow-up information in a complete client record were submitted and approved by the Department for the May 24, 2022 and July 28, 2021 annual licensing inspections. Documentation of follow-up information was again found to be a deficiency in the July 6, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/10/2023, all staff have been informed and trained based off of the plan of correction for each citation received at this licensing visit.
Moving forward, director will review current plan of correction action items in at least 10% of active client charts via a monthly randomized chart audit. |