INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensing, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on April 1, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Penn Presbyterian Medical 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:
|
Plan of Correction
|
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
|
Observations
Based on the review of patient records, the program failed to have a narcotic treatment physician document in the patient's record the basis for the determination of current dependency and evidence of a one-year history of addiction in two of four applicable patient records reviewed.Patient #2 was admitted on June 24, 2020 and was an active client at time of the inspection. A narcotic treatment physician did not document in the patient record current dependency and evidence of a one-year history of addiction.Patient #4 was admitted on May 5, 2020 and was discharged on January 27, 2021. A narcotic treatment physician did not document in the patient record current dependency and evidence of a one-year history of addiction.These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
Citation #: M059
Date to be Completed By: 05/01/21
Responsible Party: Program Medical Director ("Medical Director")
Actions:
o The Medical Director will implement the directive to program physicians as part of the medical provider program orientation and training that all new patients entering program, even if started on suboxone by outside provider, will be assessed by program physicians to ensure 1-year dependency/ history of addiction of Opiate Use Disorder (OUD).
o Medical Director will require 1-year dependency/history of addiction is documented for all patients receiving suboxone treatment.
o Program Director will update smart phrase functionality within the electronic medical record in physician notes for symptoms of Opiate Use Disorder by the following DSM-5 criteria to include "occurring within the previous 12-month period."
o Introduction of the update will be overseen by the Medical Director and is anticipated to be available within one (1) month.
o Patient records noted in findings are discharged patients and cannot be updated however the physicians were notified by Medical Director regarding future documentation compliance.
o Program Director has assigned counselors monthly chart audit responsibilities to ensure adherence to this standard during the review period. Five percent (5%) of eligible patients seen within month or 20 charts/month, whichever is greater, will be reviewed to ensure initial physicians' note includes smartphrase "occurring within the previous 12-month period" or other content demonstrating eligibility. This audit will be continued until three months of sustained compliance is achieved.
o Medical Director or his designee will report results compliance audits to the PPMC Clinical Effectiveness and Quality Improvement (CEQI) Committee as part of the Facility's quality assurance and performance improvement (QAPI) activities. The Committee will evaluate the results and implement any further process changes and audits, as needed.
o Patient #4 discharged on January 27, 2021 & Patient #2 was discharged prior to date of this report 4/27/21. No updates could be made to these noted encounters/patients' files to reflect changes specified in corrective action plan for chart to be in compliance with 715.9(a)(4) Intake.
|
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.
|
Observations
Based on the review of patient records, the program failed to obtain an informed, voluntary, written consent before an agent was administered to the patient for maintenance treatment in two of four applicable patient records reviewed.Patient #2 was admitted on June 24, 2020 and was an active client at time of the inspection. An informed, voluntary, written consent was not documented in the patient records prior to the administration of an agent for maintenance treatment.Patient #4 was admitted on May 5, 2020 and was discharged on January 27, 2021. An informed, voluntary, written consent was not documented in the patient records prior to the administration of an agent for maintenance treatment.These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
Citation #: M095
Date to be Completed By: 05/01/21
Responsible Party:
Program Medical Director ("Medical Director")
Actions:
o The Medical Director will implement the directive to program physicians as part of the medical provider program orientation and training that all new patients entering program, even if started on suboxone by outside provider, will be assessed by program physicians to ensure 1-year dependency/ history of addiction of Opiate Use Disorder (OUD).
o Medical Director will provide education on consent to all treating physicians in program to review the program requirement that "an informed, voluntary written consent be obtained before an agent may be administered to the patient for either maintenance or detoxification treatment." Completion is ongoing as new physicians start. Currently Medical Director is only physician.
o Patient records noted in findings are discharged patients and cannot be updated however the physicians were notified by Medical Director regarding future documentation compliance.
o Program Director has assigned counselors monthly chart audit responsibilities to ensure adherence to this standard during the review period. Five percent (5%) of patients seen within month or 20 charts/month, whichever is greater, will be reviewed for buprenorphine consent on file and documented per regulation to be continued until three months of sustained compliance is achieved.
o Medical Director or his designee will report results of compliance audits to the PPMC Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight.
o Patient #2 was discharged prior to date of this report 4/27/21 & Patient #4 was discharged on January 27, 2021. No updates could be made to these noted encounters/patients' files to reflect changes specified in corrective action plan for chart to be in compliance with 715.12(1-5) Informed Patient Consent.
|
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.
|
Observations
Based on the review of patient records, the program failed to each patient an average of 2.5 hours of psychotherapy per month during the patient ' s first two-years in two of four applicable patient records reviewed.Patient #2 was admitted on June 24, 2020 and was an active client at time of the inspection. There was no documentation in the patient records that the patient received the 2.5 psychotherapy hours required for the month of March 2021 and 1.5 of the 2.5 psychotherapy hours required for the months of January 2021 and February 2021.Patient #5 was admitted on March 9, 2020 and was discharged on September 10, 2020. There was no documentation in the patient records that the patient received the 2.5 psychotherapy hours required for the months of July 2020 and August and 2.0 of the 2.5 psychotherapy hours required for the month of June 2020. These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
Citation #: M185
Date to be Completed By: 5/1/2021
Responsible Party:
Facility and Program Director ("Program Director") for Behavior Health
o The Program Director reeducated staff on screening processes to verify referrals for buprenorphine are interested in participating in at minimum OP level of care (2.5 hours) before program engagement through providing detailed information regarding participation responsibilities at time of assessment. Program Director reeducated staff on verifying individuals are provided with education and information on all available treatment options to ensure individuals are well-informed and engaging in treatment that best meets their goals.
o Program Director reeducated program staff on adhering to appropriate service standards and documentation standards as outlined in 715.19(1) LICENSURE Psychotherapy services, (POLICY 1.08 - PROGRESS NOTES & POLICY) & (POLICY 2.0 -COUNSELING GUIDELINES) to be included in each patient's medical record. Education to be completed on 5/1/21.
o Program Director reeducated program staff on referral process (POLICY 3.01 - REFERRAL TO SERVICES PROVIDERS) to alternate program/provider that best meets patient's goals and ability to participate as necessary. Program staff were reeducated on confidentiality standards for release of information for referrals (POLICY 9.0 ? CONFIDENTIALITY) to ensure appropriate documentation will be included in each patient's medical record. Education was completed on 5/1/21.
o Program Director provided staff with updated direction on outreach practices updated for buprenorphine patients to include more active outreach by Counselors and Certified Recovery Specialists (CRS) within the first 2 weeks of enrollment of program. Education was completed on 5/1/21.
o Program Director provided staff with education and direction on practices surrounding patient discharge and referral practices related specifically to patients engaged in Medication Assisted Treatment (MAT treatment) when there is non-engagement in program services (POLICY 11.02 - NON-COMPLETION OF PROGRAM) Within the first 2 weeks after aggressive outreach attempts by staff, patient will be transferred to an outside provider for MAT only treatment. This will be documented in each patient's medical record.
o Patient records noted in findings are either discharged patients and/or for other reasons cannot be updated however the staff were retrained and procedures were put into place as outlined above to ensure future documentation compliance. Education was completed on 5/1/21. Completion of the training was documented in the staff members' personnel record.
o Program Director assigned counselors monthly chart auditing responsibilities to ensure adherence to standard during the review period. Five percent (5%) of charts or 20 charts/month, whichever is greater, will be audited for Consent to Release Information form compliance until three months of sustained compliance is achieved.
o Program Director or her designee will report results of compliance audits to the PPMC Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight.
o Patient #2 was discharged prior to date of this report 4/27/21& Patient #5 was discharged on September 10, 2020. No updates could be made to these noted encounters/patients' files to reflect changes specified in corrective action plan for chart to be in compliance with 715.19(1) Psychotherapy Services.
|
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on the review of client records, the project failed to document an updated treatment and rehabilitation plans at least very 60-days in four of seven client records reviewed.Client # 2 was admitted on June 24, 2020 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan was completed on July 30, 2020 and the treatment and rehabilitation plan update was due no later than September 30, 2020; however, an update was not documented in the client record until October 15, 2020. Additionally, an updated treatment and rehabilitation plan was completed on October 15, 2020 and the next update was due no later than December 15, 2020; however, an update was not documented in the client record until December 31, 2020. Client #4 was admitted on May 5, 2020 and was discharged on January 27, 2021. A comprehensive treatment and rehabilitation plan was completed on May 5, 2020 and the treatment and rehabilitation plan updates were due no later than July 5, 2020, September 7, 2020, November 7, 2020 and January 7, 2021; however, there were no updated treatment and rehabilitation plans documented in the client record at the time of the inspection.Client #5 was admitted on March 9, 2020 and was discharged on September 10, 2020. A comprehensive treatment and rehabilitation plan was completed on March 24, 2020 and the treatment and rehabilitation plan update was due no later than May 24, 2020; however, an update was not documented in the client record until June 8, 2020.Client #6 was admitted on March 10, 2020 and was discharged on October 6, 2020. A treatment and rehabilitation plan update was completed on June 30, 2020 and the next update was due no later than August 30, 2020; however, an update was not documented in the client record at the time of the inspection.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Citation #: 0969
Date to be Completed By: 4/2/21
Responsible Party:
Facility and Program Director ("Program Director") for Behavior Health
Actions:
o The Program Director provided staff education to staff including counselors (and team) of treatment plan expectations in alignment with 711.92(d) LICENSURE Tx Plan Update. Initial treatment plan is completed upon admission and is working Treatment Plan for first 30 days of patient's treatment, treatment plan updates occur (at minimum) every 60 days after, and/or after any significant change/event in the patient's course of treatment. Education occurred on 4/2/21.
o As outlined in their role expectations and counselor training, Counselors, are responsible for ensuring that all patients assigned to them have treatment plan updates completed according to standards. Counselors developed plan to assist with a reminder system to ensure they do not miss dates for updates as they are individual to each patient based on admission through creating electronic calendar reminders to verify treatment plans are completed on time in accordance with individual patient's admission date. Counselors began implementing this process after training occurred on 4/2/2021.
o Patient records noted in findings are either discharged patients and/or for other reasons (past due dates) cannot be updated however the staff were retrained and procedures were put into place as outlined above to ensure future documentation compliance. Education was completed on 4/2/21. Completion of the training was documented in the staff members' personnel record.
o Program Director assigned counselors monthly chart auditing responsibilities to ensure adherence to standard during the review period. Five percent (5%) of charts or 20 charts/month, whichever is greater, will be audited for Consent to Release Information form compliance until three months of sustained compliance is achieved.
o Program Director or her designee will report results of compliance audits to the PPMC Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight.
o Patient #2 was discharged prior to date of this report 4/27/21, Patient #4 was discharged on January 27, 2021, Patient #5 was discharged on September 10, 2020 & Patient #6 was discharged on October 6, 2020. No updates could be made to these noted encounters/patients' files to reflect changes specified in corrective action plan for chart to be in compliance with 711.92(d) Treatment and rehabilitation services. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of seven client records reviewed.Client #4 was admitted on May 5, 2020 and was discharged on January 27, 2020. A release of information form for the funding source was not documented in the client record. Client #7 was admitted on March 19, 2020 and was discharged on March 11, 2021. A release of information form for the funding source was not documented in the client record. These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Citation #: 0999
Date to be Completed By: 4/2/21
Responsible Party:
Facility and Program Director ("Program Director") for Behavior Health
Action:
o Program Director reviewed POLICY 9.0 ? CONFIDENTIALITY, and the corresponding Consent to Release of Information form. Completed 4/2/2021. The review revealed an opportunity to re-educate unit staff on the procedures outlined in the policy.
o Program Director provided program staff with reeducation surrounding standards of confidentiality and release of information (POLICY 9.0 ? CONFIDENTIALITY) to verify that all outside referrals/resources including funding sources have a consent to release information prior to release of any information in accordance with 28 Pa Code 711.93(c). Education was completed on 4/2/21.
o Program Director advised staff that all consents to release information are to be provided to Patient Services Representatives (PSR) for immediate (same/next business day) scanning into patient's record. Consents must be in patient's record before any information may be exchanged. Education was completed on 4/2/21
o Patient records noted in findings are either discharged patients and/or for other reasons cannot be updated. However, the staff were retrained and procedures were put into place as outlined above for future documentation compliance. Education was completed on 4/2/21. Completion of the training was documented in the staff members' personnel record.
o Program Director assigned counselors monthly chart auditing responsibilities to ensure adherence to standard during the review period. Five percent (5%) of charts or 20 charts/month, whichever is greater, will be audited for Consent to Release Information form compliance until three months of sustained compliance is achieved.
o Program Director or her designee will report results of compliance audits to the PPMC Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight.
o Patient #4 was discharged on January 27, 2021 & Patient #7 was discharged on March 11, 2021. No updates could be made to these noted encounters/patients' files to reflect changes specified in corrective action plan for chart to be in compliance with 711.93(c)(2) Client records. |
711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(ii) The specific information disclosed.
|
Observations
Based on a review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in four of seven client records reviewed. Additionally, client record #1 was missing the specific information to be released.Client #1 was admitted on December 1, 2020 and was an active client at the time of the inspection. A release of information form to a laboratory, signed and dated by the client on December 1, 2020, was missing the specific information to be disclosed.Client #2 was admitted on June 24, 2020 and was an active client at time of the inspection. A release of information form to a funding source, signed and dated by the client on June 24, 2020, allowed for the release of progress notes, which exceeds the limits established by 4 Pa. Code 255.5.Client #5 was admitted on March 9, 2020 and was discharged on September 10, 2020. A release of information form to a funding source, signed and dated by the client on March 9, 2020, allowed for the release of progress notes, which exceeds the limits established by 4 Pa. Code 255.5.Client #6 was admitted on March 10, 2020 and was discharged on October 6, 2020. A release of information form to a funding source, signed and dated by the client on March 10, 2020, allowed for the release of case management notes, physician orders, progress notes, discharge summary, medical history and physical exam, all of which exceeds the limits established by 4 Pa. Code 255.5.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Citation #: 1003
Date to be Completed By: 4/2/21
Responsible Party:
Facility and Program Director ("Program Director") for Behavior Health
Action:
o Program Director provided program staff with reeducation surrounding adherence of standards to POLICY 9.00 ? CONFIDENTIALITY aligning with 711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed. Staff was provided with guidance on properly completing Consent to Release Information. Staff attendance and completion of this training was documented in staff personnel records. Education was completed on 4/2/21.
o Patient records noted in findings are either discharged patients and/or for other reasons cannot be updated. However, the staff were retrained and procedures were put into place as outlined above for future documentation compliance. Education was completed on 4/2/21. Completion of the training was documented in the staff members' personnel record.
o Program Director advised staff that all consents to release information are to be provided to Patient Services Representatives (PSR) for immediate (same/next business day) scanning into patient's record. Consents must be in patient's record before any information may be exchanged. Education was completed on 4/2/21.
o Program Director assigned counselors monthly chart auditing responsibilities to ensure adherence to standard during the review period. Five percent (5%) of charts or 20 charts/month, whichever is greater, will be audited for Consent to Release Information form compliance until three months of sustained compliance is achieved.
o Program Director or her designee will report results of compliance audits to the PPMC Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight.
o Patient #1 was discharged prior to date of this report 4/27/21, Patient #2 was discharged prior to date of this report 4/27/21, Patient #5 was discharged on September 10, 2020 & Patient #6 was discharged on October 6, 2020. No updates could be made to these noted encounters/patients' files to reflect changes specified in corrective action plan for chart to be in compliance with 711.93(c)(2)(ii) Client records. |