INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18-19, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Stepping Stones Unit @ Meadville 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:
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of administrative information, the facility failed to collect feedback on completed trainings in two of ten personnel records reviewed.
Facility policy and procedures state that feedback forms are to be completed after each training.
The training year beginning January 1, 2023, through December 31, 2023 was reviewed and feedback was not collected for each training.
Staff #1 was hired on November 1, 2021.
Staff #3 was hired on May 31, 2009.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Existing policy updated to address the process that will take place. Staff involved were reminded and re-oriented to the the Learning Activity Records which is the process utilized to capture staff training activity and staff feedback on each course and how needs were met by each course. Program Supervisor and Outreach Coordinator will track trainings in real time throughout the training year to capture all necessary credits and to insure that the Learning Activity Record is completed by all staff involved. |
710.23(b) LICENSURE Patient Records
§ 710.23. Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code § § 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects; and coordinating bodies: disclosure of client-oriented information).
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Observations
Based on a review of client records, the facility failed to follow accordance with applicable Federal drug and alcohol regulations in the disclosure of client-oriented information to be disclosed in two of seven records reviewed.
Client #1 was admitted to the detox level of care on April 14, 2024, and discharged on April 26, 2024. A release to a primary care physician was signed by the client on April 14, 2024, and did not indicate specific information to be disclosed.
Client #3 was admitted to the detox level of care on March 6, 2024, and discharged on March 12, 2024. A release to a primary care physician was signed by the client on March 6, 2024, and did not indicate specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The consent form utilized in these instances has been removed from our department-specific electronic forms collection link so that it can no longer be printed out and utilized. This will enforce regulations that staff members must adhere to, to provide the information being released. Orientation to that process as well as examples of specific consents to be used as reminders are available to staff on a 24 hour per day basis. Program Supervisor and night shift charge nurses will monitor charts more thoroughly to make sure nothing has been left out of any consent. This process was reviewed with all staff via email on 10/15/24. |
710.42(c) LICENSURE Treatment and Rehabilitation Services
§ 710.42. Treatment and rehabilitation services.
(c) Treatment and rehabilitation plans shall be reviewed and updated at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates every 15 days in two of five applicable records.
Client #10 was admitted to the inpatient level of care on June 20, 2024, and discharged on July 25, 2024. A treatment plan was completed on June 26, 2024, and the update was due no later than July 11, 2024; however, the update was completed on July 19, 2024.
Client #11 was admitted to the inpatient level of care on May 14, 2024, and discharged on June 3, 2024. A treatment plan was completed on May 20, 2024, and the update was due no later than June 4, 2024; however, there were no updates in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting was held with all inpatient counseling staff regarding this regulation and policy on September 20, 2024. Meeting was held by Program Supervisor (this writer) and addressed the policy and the specific infractions were reviewed and the correct process discussed. Counselors' preceptor was in attendance and re-oriented staff to the process to which they had all been trained, and all questions were addressed. The Program Supervisor will check weekly to insure that updates are in place for all patients' master treatment plans. |
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:
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one of seven records reviewed.
Client #19 was admitted to the outpatient level of care on March 6, 2024, and was still an active client at the time of inspection.
There was no consent to release information form for the funding source in the record. Facility staff confirmed billing had occurred.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Supervisor will investigate to see whether an expiration date can be added to the existing consent signed throughout the entire medical center, that allows for the patient to be billed and treated by the department involved. Intake staff were advised as a reminder to make sure that all patients being assessed, whether or not they are coming from our inpatient program, sign a release to allow communication with their funding entities for both physical health plans and behavioral health plans. Unit coder and biller/secretary will review each chart in the outpatient department as will individual counselors should the therapy be continuing as the expiration date of the original consent approaches, to make sure a renewed consent is obtained. Inpatient counselors will be responsible for making sure no consents expire during the course of inpatient treatment. |