INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 15, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mercy Behavioral Health 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)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of applicable staff records, the facility failed to document staff had completed HIV/AIDS and TB/STD training within the required timeframe in one of three staff records.
Staff #3 was hired as a counselor on September 11, 2023 and was still in this position at the time of the inspection. HIV/AIDS and TB/STD trainings were to be completed by September 11, 2024. The HIV/AIDS training was completed on March 19, 2025. There was no documentation the TB/STD training was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #3 has requested and been approved for the TB/STD/Hepatitis class that will take place on 06/27/25.
To ensure this does not occur in the future, upon a new hire beginning, the supervisor will insert the required DDAP training list into the monthly supervision log template, along with the due dates, and will monitor on a monthly basis at minimum for compliance. |
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 applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure in two of three records.
The policy and procedure indicates follow-up contact must be made within thirty days after discharge.
Client #6 was admitted on May 6, 2024 and was discharged on September 19, 2024. Follow-up contact was due to be completed no later than October 19, 2024, however, this was not completed until November 19, 2024.
Client #7 was admitted on May 21, 2024 and was discharged on July 17, 2024. Follow-up contact was due to be completed no later than August 17, 2024, however, this was not completed until September 27, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility policy has been amended to reflect a new workflow. The workflow includes the additional option of sending a letter to the person served after discharge from an SUD program. The letter will contain directions to re-engage in our services or contact us for needed supports; as well as how to find crisis management resources.
We have changed the facility time-constraint from 30 days to now reflect 90 days. The new workflow is below:
Supervisor will run a report of all persons served discharged from SUD services twice per month and send report to the Engagement Care Managers to conduct follow-up.
Engagement Care Managers will monitor discharges to ensure each person served is contacted within 90 days post-discharge. When the person served is contacted, the colleague will request that the person served complete, via phone, the follow-up form, available in the electronic health record titled "Discharge Follow Up"
Any issues identified on the Discharge Follow Up form will be addressed immediately during the call. Additionally, the colleague will offer referrals to appropriate services, either through Pittsburgh Mercy or other external providers, and facilitate the referral process if accepted by the person served.
The colleagues responsible for completing the Discharge Follow Up form and coordinating any referrals will document the outcomes of the follow-up in the persons served electronic health record, ensuring that all relevant information is accurately captured for continuity of care.
If the person served has a phone number that is not in service, no phone number listed, or there is an inability to leave a message, a letter will be sent to the person served via the persons served address in the electronic health record.
Supervisor will monitor the tracking sheet monthly at minimum, to ensure follow-up is being conducted per policy.
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