INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 9, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the 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.
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Plan of Correction
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711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) 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
The facility failed to properly document the frequency of services the client was to receive on the client's individual treatment plan in three of seven client records reviewed.
Client # 1 was admitted on October 17, 2018 and was active at the time of inspection. The comprehensive treatment plan was dated November 5, 2018.
Client # 2 was admitted on May 2, 2019 and active at the time of the inspection. The comprehensive treatment plan was dated May 21, 2019.
Client # 7 was admitted on August 10, 2018 and was discharged on August 6, 2019. The comprehensive treatment plan was dated September 12, 2018.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
1.Policy 1.07: Treatment Planning was reviewed by the Clinical Manager for the outpatient Drug and Alcohol Services and the Project/Facility Director on August 9, 2019. The review revealed that no changes needed to be made to policy 1.07 Treatment Planning and that there was an opportunity to re-educate staff on the procedures outlined in the policy.
2.Unit staff were reeducated on Policy 1.07 Treatment Planning on August 12, 2019 including procedure I. A. 3 for "content" of treatment plan: "the type and frequency of treatment services to be rendered". Staff were trained on the use of including S.M.A.R.T (Specific, Measurable, Attainable, Realistic and Time Specific) goals within the treatment plans to ensure adherence. Staff attendance and completion of this training was documented in staff personnel records. Training will occur on hire for new employees and as needed thereafter.
3.The Electronic Medical Record (EMR) launched in the beginning of July 2019 was built to assist the counselors with the development of appropriate measurable goals for presenting patient issues. The EMR was optimized to include a documentation template to assist the counselors with writing measurable goals that adhere to standard 711.92 (C) (2).
4. Completion of counselor trainings to review Policy 1.07 Treatment Planning, S.M.A.R.T goals and optimization of the EMR occurred on August 12, 2019. Completion of trainings were documented in training development in staff member's personnel records.
5.No changes could be made to Client # 1's comprehensive treatment plan as it was signed and dated. On August 12, 2019, primary counselor was educated on ensuring treatment plans remain in compliance with specified date, including ensuring future updates to Client 1 #'s treatment plans occur at least 1 time every 60 days as per policy.
6.No changes could be made to Client # 2's comprehensive treatment plan as it was signed and dated. On August 12, 2019, primary counselor was educated on ensuring treatment plans remain in compliance with specified date including ensuring future updates to Client 2 #'s treatment plans occur at least 1 time every 60 days as per policy.
7.No changes could be made to Client # 7's comprehensive treatment plan as it was signed and dated. Client #7 was discharged on September 12, 2018 so there will be no future update to treatment plans. On August 12, 2019, primary counselor was educated on ensuring all treatment plans remain in compliance with specified date.
Methodology for Achieving and Maintaining Compliance:
A chart audit process implemented by the Clinical Manager for the outpatient Drug and Alcohol Services or her designee will include a review of at least 30 visits a month during the review period to verify that the initial treatment plan, comprehensive treatment plan and treatment plan updates contain measurable goals that are clearly defined and based on the patients presenting concerns. Compliance will be tracked monthly by the manager, and the audit will continue until three consecutive months of sustained compliance have been achieved. The data will be reported monthly by the clinical supervisor to the Behavioral Health/Drug and Alcohol Unit Based Clinical Leadership and the Clinical Effectiveness and Quality Improvement (CEQI) Committee as part of the Facility's quality assurance and performance improvement activities. The team will evaluate the results and implement any further process changes and audits, as needed. The audit began following the completion of the counselor education.
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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.
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Observations
The facility failed to provide treatment plan updates within the regulatory timeframe in four of six applicable client records reviewed.
Client # 1 was admitted on October 17, 2018 and was still active at the time of the inspection. The comprehensive treatment plan was completed on November 5, 2018 with an update due no later than January 5, 2019; however, the update was completed January 28, 2019. Additionally, a treatment plan update was completed on March 29, 2019 with an update due no later than May 29, 2019 however, no update was completed at the time of the inspection.
Client # 2 was admitted on May 2, 2019 and was still active at the time of the inspection.
The comprehensive treatment plan was completed on May 21, 2019 with an update due no later than July 21, 2019; however, no update was completed at the time of the inspection.
Client # 5 was admitted on October 29, 2018 and was discharged on March 21, 2019. The comprehensive treatment and rehabilitation plan was completed on December 9, 2018 with an update was due no later than February 9, 2019; however, no update was completed prior to discharge.
Client # 7 was admitted on August 10, 2018 and was discharged on August 6, 2019. A treatment plan update was completed on January 11, 2019 with an update was due no later than March 11, 2019; however, the update was completed on April 26, 2019. Additionally, a treatment plan update was completed on May 13, 2019 with an update due no later than July 13, 2019; however, no update was completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Policy 1.07: Treatment Planning was reviewed by the Clinical Manager for the outpatient Drug and Alcohol Services and the Project/Facility Director on August 12, 2019. The review revealed that no changes needed to be made to policy 1.07 Treatment Planning and that there was an opportunity to re-educate staff on the procedures outlined in the policy.
2. Unit staff were reeducated on Policy 1.07 Treatment Planning on August 19, 2019 including procedure regarding timeframes for completion of patient documentation: that treatment plans shall be reviewed and updated at least every 60 days. Staff were trained on the use of the scheduling tool within the Electronic Medical Record to schedule patient activity reminders that would allow for the treatment plan reminder within the 60-day timeframe. Staff were trained on the use of including S.M.A.R.T (Specific, Measurable, Attainable, Realistic and Time Specific) goals within the treatment plans to ensure adherence. Completion of trainings were documented in training development in staff member's personnel records. Training will occur on hire for new employees and as needed thereafter.
3. Client # 1's assigned counselor reached out to patient to schedule session on August 12, 2019. Update was completed and documented in patient's chart on August 16, 2019.
4. Client # 2's assigned counselor attempted outreach to patient to schedule session on August 12, 2019. Counselor left role in program and newly assigned counselor attempted outreach to patient to schedule session for Treatment Plan Update to occur on August 22, 2019 and then August 28, 2019. Patient did not present to sessions therefore Treatment Plan Update has not been completed. Assigned counselor has documented Client #11's chart accordingly. Assigned counselor will continue outreach to re-engage patient in services and ensure Treatment Plan Updates are completed.
5. No update was able to be made to Client # 5's chart as he was discharged December 9, 2018.
Assigned counselor was reeducated on Policy 1.07 Treatment Planning on August 12, 2019 including procedure regarding timeframes for completion of patient documentation including that treatment plans shall be reviewed and updated at least every 60 days. Completion of training was documented in counselor's personnel record.
6. No update was able to be made to Client # 7's chart as he was discharged on August 6, 2019. Assigned counselor was reeducated on Policy 1.07 Treatment Planning on August 12, 2019 including procedure regarding timeframes for completion of patient documentation including that treatment plans shall be reviewed and updated at least every 60 days. Completion of training was documented in counselor's personnel record.
Methodology for Achieving and Maintaining Compliance:
The manager of the outpatient unit will implement an audit process by management and a peer review process to include that each month clients file from at least (5) active patients from each counselor caseload (totaling at 20 files) during the review period will be reviewed to ensure treatment plans are being reviewed and updated at least every 60 days. Compliance will be tracked monthly, and the audit will continue until three consecutive months of sustained compliance has been achieved. The data will be reported monthly by the clinical supervisor to the Behavioral Health/Drug and Alcohol Unit Based Clinical Leadership and Clinical Effectiveness and Quality Improvement (CEQI) Committees as part of the Facility's quality assurance and performance improvement activities. The team will evaluate the results and implement any further process changes and audits, as needed. The audit began following completion of staff education.
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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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed. Additionally, the facility failed to document all elements of the consent form in two of seven client records reviewed.
Client # 1 was admitted on October 17, 2018 and was active at the time of the inspection. There was documentation of that a facsimile was sent to another treatment provider on February 20, 2019 and May 30, 2019; however, there was no consent to release information form on file prior to disclosure.
Client # 2 was admitted on May 2, 2019 and was active at the time of the inspection. There a consent form to a transportation agency and the funding source signed and dated by on May 2, 2019; however, the form was missing a witness signature. Additionally, there was a consent form to two family members signed and dated by the witness on May 2, 2019; however, the consent form was missing a dated client signature.
Client # 3 was admitted on January 2, 2019 and was active at the time of the inspection. There was a consent form to the funding source signed and dated by the client on January 2, 2019; however, the consent form was missing the items to be disclosed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. On August 12, 2019, Disclosure of Confidential Information Policy (11.01) was reviewed by the Clinical Manager for the outpatient Drug and Alcohol Services and the Project/Facility Director. The review revealed an opportunity to amend the policy to include the need to obtain patient consent for the release of information.
2. The current Consent to Release Information form was also reviewed on August 12, 2019 by the Clinical Manager for the outpatient Drug and Alcohol Services and the Project/Facility Director and amended to include the need to obtain patient consent for release of information to any individual outside the treatment team. The amended Consent to Release Information from also includes instructions on what information is to be released, for what purpose, and under what circumstances information can and cannot be released and to whom in accordance with 42 CFR Part 2.
3. Unit staff including counselors, physicians and nursing staff were re-educated by August 19, 2019 on the requirements of the Disclosure of Confidential Information Policy (11.01), including that no information can be disclosed to outside persons or entities, including information relating to the involvement in treatment and sessions, without the patient first completing a Consent to Release Information form. The education stressed the need for information in the form being properly explained to the patient including: (a) what is and is not to be released and to whom, and (b) the boundaries and limitations of the consent including the patient's right to revoke consent. Staff were trained on consent for release of information form and on how to appropriately explain it to patients and complete it in its entirety by the manager. Completion of trainings were documented in training development in staff member's personnel records. Training and required annual trainings regarding protecting confidentiality and release of information in accordance to federal and state guidelines as well as 42 CFR Part 2 will occur on hire for new employees and as needed thereafter.
4.Client # 1's assigned counselor reached out to patient to schedule session on August 12, 2019. Consent for Release of Information form was completed and documented in patient's chart on August 16, 2019.
5.Client # 2's assigned counselor attempted outreach to patient to schedule session on August 12, 2019. Counselor left role in program and newly assigned Counselor attempted outreach to patient to schedule session to complete Consent for Release of Information form to occur on August 22, 2019 and then August 28th, 2019. Patient did not present to sessions therefore Consent for Release of Information form has not yet been completed. Assigned counselor has documented Client #11's chart accordingly. Assigned counselor will continue outreach to re-engage patient in services and ensure Consent for Release of Information forms are completed at the client's next scheduled session.
6.Client # 3's assigned counselor reached out to patient to schedule session on August 12, 2019. Patient has not presented for sessions therefore Consent for Release of Information form has not yet been completed. Assigned counselor has documented Client # 3's chart accordingly. Assigned counselor will continue outreach to re-engage patient in services and ensure Consent for Release of Information forms are completed at the client's next scheduled session.
Methodology for Achieving and Maintaining Compliance:
Project Director/Facility Director for Drug and Alcohol Services or her designee will monitor adherence to proper use and completion of consents to release information through conducting quality audits to include a review of a minimum of thirty (30) consent for release of information forms each month during the review period. This review will consist of verifying that all required fields of the consent form are completed appropriately. Compliance will be tracked monthly, and the audit will continue until three consecutive months of sustained compliance has been achieved. Documentation of outside contact regarding patient will also be cross-checked to ensure appropriate consent to release information for each contact was completed. The team will evaluate the results and implement any further process changes and audits, as needed. The data will be reported monthly by the clinical supervisor to the Behavioral Health/Drug and Alcohol Unit Based Clinical Leadership and Clinical Effectiveness and Quality Improvement (CEQI) Committees as part of the Facility's quality assurance and performance improvement activities. The team will evaluate the results and implement any further process changes and audits, as needed. The audit began following completion of staff education.
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