INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 25, 2017 through January 27, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Penn Foundation for Mental Health, Inc. 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(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff schedules and CPR certification cards, the facility failed to provide a sufficient number of staff persons certified in CPR during the project's hours of operation.
Staff schedules and CPR certification cards for the period covering December 25, 2016 through January 21, 2017 were reviewed on January 25, 2017 through January 27, 2017.
There was a lack of sufficient CPR coverage for the following days and shifts: January 5, 2017 from 11:00pm-7:00am and January 14, 2017 from 3:00pm-11:00pm.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The Inpatient program director has established a new tracking system during March supervision with the Director of nursing that assures the timely completion of staff for the mandatory CPR certification process and assuring the presence of sufficient numbers of certified CPR staff are on site at all times. A new work flow has been added to the scheduling process by the Inpatient program director and director of nursing to assure as part of the auditing of implementation there is CPR certification coverage on a daily schedule basis. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project directors and facility directors in one of two personnel records reviewed.
Twenty personnel records were reviewed on January 25, 2017, one of which was identified as a project director and one as a facility director. The facility training year was from January 1, 2015 through June 30, 2016. Employee #1 was hired as the project director on September 13, 2010 and only completed 1.5 clock hours of annual training during the training year that was reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Pennfoundation Project Director will obtain documentation for stated training hours. If documentation does not become provided registration items will be available as substantiation of 12 training hours as stated. Training hours will be audited and reviewed annually to assure 12 training hours are documented. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in two of three personnel records reviewed.
Twenty personnel records were reviewed on January 25, 2017, three of which were identified as counselors. The facility training year was from January 1, 2015 through June 30, 2016. Employee #17 was hired as a counselor on April 20, 2015 and only completed 19.25 clock hours of annual training during the training year that was reviewed. Employee #18 was hired as a counselor on July 8, 2013 and only completed 2.5 clock hours of annual training during the training year that was reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Outpatient program director will set a new work flow in auditing training hours on a annual basis to assure these two part time staff obtain the required 25 hours of training and are substantiated with documentation. A mid training year report will be audited by the outpatient program director to monitor timely obtainment of hours required. This will allow proactive obtainment of required hours. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The written fire drill record for the inpatient program dated January 2016, February 2016, March 2016, April 2016, May 2016, June 2016, July 2016, September 2016, November 2016 and December 2016 indicated that only one exit route was used during each drill, specifically the concrete ramp side entrance. Additionally, there was no documentation that an unannounced fire drill was conducted in August 2016 or October 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Inpatient program director will review/retrain the policy and procedure with the staff shift lead identified to manage the monthly residential fire drills. A new work flow of monitoring monthly submission by the Inpatient program director will be added to assure monthly completion of residential fire drills. |
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
Nineteen client records were reviewed on January 25, 2017 through January 27, 2017. The facility failed to obtain a consent to release information form for information released to a funding source in one of nineteen client records reviewed.
Client #3 was admitted into the partial hospitalization program on August 5, 2016 and discharged on August 30, 2016. The client record did not contain documentation of an informed and voluntary consent for the client's funding source. An interview with the clinical supervisor confirmed that the facility was billing the funding source without an informed and voluntary consent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the month of March the Outpatient Program Director will conduct supervision with all staff around reviewing the policy and procedures of confidentiality and obtaining releases, especially for funding sources. During the process of random chart audit this area will be audited to see if there are any further training needs. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Nineteen client records were reviewed for client rights from January 25, 2017 through January 27, 2017. There was a sign off sheet in each record that indicated that the client was informed of their rights and were offered a copy of the client rights policy. The client rights policy was missing the following verbiage: handicap.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Outpatient program director will add the verbiage "handicap" to the drug and alcohol client rights policy. Once this document is updated by 3/15/2017 this new revised policy will be placed in the clients handbook for dissemination. |
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 the review of the facility's policy and procedure manual on January 25, 2017, the facility failed to develop and implement policies and procedures to respond to the following unusual incidents:
709.30 (a)
(3)death or serious injury due to trauma, or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services
(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
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Penn Foundation Compliance officer revised the Pennfoundation unusual incident policies and procedures to include all the parameters stated under 709.30 (a).All parameters under 709.30 have been developed and operationalized by the Inpatient program director and outpatient program director. |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
Based on the review of the facility's policy and procedure manual on January 25, 2017, the facility failed to develop and implement policies and procedures that included:
709.34 (b)
(5) reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Pennfoundation compliance officer revised the Pennfoundation unusual incident report policy and procedure to include 709.34 (b) (5). The Outpatient and Inpatient program directors will assure system awareness of this policy change during staff meetings in March 2017. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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
Five client records were reviewed on January 25, 2017 through January 27, 2017 for treatment and rehabilitation services in the partial hospitalization activity.
Client #3 was admitted on August 5, 2016 and discharged on August 30, 2016. There was no comprehensive treatment plan documented in the record.
Client #5 was admitted on June 17, 2016 and discharged on July 11, 2016. The comprehensive treatment plan dated July 6, 2017 did not identify the frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The outpatient program director will train the partial hospitalization staff on completing a comprehensive treatment plan when someone steps down from a higher level of care by 3/31/2017. Staff will be supervised to assure a treatment plan is completed for all persons admitted to partial. The outpatient program director will add this area to the monthly audit of charts to assure partial hospitalization staff are completing treatment plans for all admissions. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on the review of patient records, the facility failed to document verification that the patient reached 18 years of age prior to the administration of Buprenorphine in one of five records reviewed.
Five patient records were reviewed from the short-term detoxification activity on January 25, 2017 through January 27, 2017. Patient #3 was admitted to the detox program on September 21, 2016 and discharged on September 28, 2016. Patient record #3 did not contain verification that the patient reached 18 years of age prior to the administration of Buprenorphine.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Inpatient program Director will train the intake/admission staff on assuring documentation that the patient reached 18 years of age. A new process will be added when a individual is transferred form another facility to assure documentation is obtained. During monthly chart audits this area will be added to assure follow through. |
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 the review of patient records, the facility failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification in two of four records reviewed.
Five patient records were reviewed from the partial hospitalization activity and four patient records were reviewed from the outpatient activity on January 25, 2017 through January 27, 2017. Four of which were identified as receiving buprenorphine as part of their treatment.
Patient #5 was admitted to the partial hospitalization program on June 17, 2016 and discharged on July 11, 2016. The patient record contained documentation that the patient was given a prescription for Buprenorphine on June 27, 2016. There was no documentation of an informed, voluntary written consent prior to the administration of a narcotic agent in patient record.
Patient #4 was admitted to the outpatient program on April 18, 2016 and discharged on June 21, 2016. The patient record contained documentation that the patient was given a prescription for Buprenorphine on May 24, 2016. There was no documentation of an informed, voluntary written consent prior to the administration of a narcotic agent in patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will assure the outpatient and partial levels of care have available to them the buprenorphine consent in the electronic health record. The medical Director will assure medical staff are trained and implementation of this document. This new document in the electronic health record was established on 2/20/2017. All medical staff have been trained on assuring consent during the evaluation that has medically determined the prescribing of buprenorphine. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on the review of patient records, the facility failed to ensure that an initial drug screening urinalysis was completed prior to the administration of Buprenorphine in one of two records reviewed.
Five patient records were reviewed from the partial hospitalization activity on January 25, 2017 through January 27, 2017. Two of which were identified as receiving buprenorphine as part of their treatment. Patient #5 was admitted to the partial hospitalization program on June 17, 2016 and discharged on July 11, 2016. Patient record #5 contained documentation that the patient was given a prescription for Buprenorphine on June 27, 2016, but the drug screen urinalysis results from the lab were not reported to the facility until June 28, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The outpatient program director will coordinate with the support staff and outpatient counselors to assure that as part of the referral application a urine drug screen is present in the buprenorphine referral process. The prescribers will be trained to assure documentation and review prior to prescribing this agent. This will be audited by the outpatient program director on a random basis to assure compliance. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
Based on the review of the facility's policy and procedure manual on January 25, 2017, the facility failed to develop and implement policies and procedures that included:
715.28 (a)
(2) inappropriate behavior by a patient causing disruption to the narcotic treatment program
(5) death or serious injury due to trauma or unusual circumstances
(6) significant disruption of services due to disaster such as fire, storm, flood or other occurrence
(7) incident with potential for negative community reaction or which the facility director believes may lead to community concern
(9) drug related hospitalization of a patient
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Pennfoundation Compliance officer has developed and implemented a revised unusual incident policy and that includes all stated areas under 715.28 (2)(5)(6). New policies and procedures were outlined in a new policy by the outpatient program director that establishes procedures for 715.28 (7)(9). The policy and procedures were updated and implemented on 3/01/2017. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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
Five client records were reviewed on January 25, 2017 through January 27, 2017 for treatment and rehabilitation services in the inpatient non-hospital residential treatment and rehabilitation activity.
Client #1 was admitted on November 17, 2016 and discharged on December 8, 2016. The comprehensive treatment plan dated November 22, 2016 did not identify the frequency of treatment and rehabilitation services.
Client #2 was admitted on July 6, 2016 and discharged on July 27, 2016. The comprehensive treatment plan dated July 7, 2016 did not identify the frequency of treatment and rehabilitation services.
Client #3 was admitted on October 16, 2016 and discharged on October 23, 2016. The comprehensive treatment plan dated October 19, 2016 did not identify the frequency of treatment and rehabilitation services.
Client #4 was admitted on September 28, 2016 and discharged on October 14, 2016. The comprehensive treatment plan dated September 30, 2016 did not identify the frequency of treatment and rehabilitation services or support services.
Client #5 was admitted on December 21, 2016 and discharged on January 9, 2017. The comprehensive treatment plan dated December 22, 2016 did not identify the frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the February group supervision with counseling staff the Inpatient Program Director will train staff on assuring full completion of the treatment plan by re-training staff on areas available on frequency with in the electron health record. During monthly random chart audits the Inpatient Program Director will identify further training needs. Supervision will be provided as need be with the pertinent counseling staff. |
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
Four client records were reviewed on January 25, 2017 through January 27, 2017 for treatment and rehabilitation services in the outpatient activity.
Client #1 was admitted on July 4, 2016 and discharged on August 30, 2016. There was no documentation of a comprehensive treatment plan contained in the record.
Client #4 was admitted on July 27, 2016 and discharged on October 24, 2016. There was no documentation of a comprehensive treatment plan contained in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the month of March during group supervision the outpatient program director will re-train staff on the policy of completions of treatment plans. The counseling staff will be trained on the requirement of timeliness. The outpatient program director will monitor this on a monthly random chart audit basis to identify any further supervisory needs. |