INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 16, 2019 through October 17, 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, John F. Kennedy Behavioral Health 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
The facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for clients in two of eleven client records.
Patient #10 was admitted on February 12, 2019 and was active at the time of inspection. The policy and procedure manual stated that the preliminary treatment plan must be completed at the first meeting. The client record had a preliminary treatment plan; however, the plan was outside of the first meeting policy.
Patient #11 was admitted on July 3, 2018 and was discharged March 3, 2019. The policy and procedure manual stated that the preliminary treatment plan must be completed at the first meeting. The client record had a preliminary treatment plan; however, the plan was outside of the first meeting policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/4/19, Intake staff will participate in a training to ensure the timely completion of the preliminary treatment plans for our clients. The clinical supervisor will be responsible for providing the training. The clinical supervisor will also be responsible for ongoing monitoring of compliance with the our policy/procedure and this standard via weekly clinical record reviews and staff supervision. |
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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of eleven patient records reviewed.
Patient #3 was admitted on May 3, 2005 and was still active at the time of the inspection. There was a consent form to the funding source signed by the client on March 20, 2018 and expired March 20, 2019. There was evidence of billing from the client's admission through the date of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 11/4/19, staff will participate in a training on the timely completion of consent to release information forms for all clients. The clinical supervisor will be responsible for conducting the training. As part of the training, staff will be instructed to review their case management logs daily to prevent over-looking due dates for these documents. In addition, the consent forms for client #3 will be updated by her counselor on October 29, 2019. The clinical supervisor will also be responsible for monitoring compliance with the standard via weekly clinical record reviews, staff supervision, and review of staff case management logs. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to document the name of the person to whom the disclosure was to be made to on a consent form in one of eleven client records.
Patient #11 was admitted on July 3, 2018 and was discharged March 3, 2019. There was a consent to release information form signed and dated by the client on July 3, 2018; however, the consent form did not include the specific name of the person/agency/organization to whom the disclosure was to be made to.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This client reported that he did not have an emergency contact person. However, the staff person attempted to complete the form because she understood the entire consent release packet could not be completed unless all forms contained in the packet are completed and signed. Emergency contact forms must be left blank or deleted from the packet if a client does not choose to designate an emergency contact.
By 11/4/19 staff will receive training to clarify management of emergency consents when clients do not designate a specific person or entity. The clinical supervisor will be responsible for conducting the training. The clinical supervisor will also be responsible for monitoring compliance with the standard via a careful review of emergency release forms prior to a applying supervisory sign-off. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of eleven client records reviewed.
Patient #9 was admitted on January 28, 2019 and was active at the time of inspection. A consent to release information form to the funding source was signed and dated by client and allowed for the release of all treatment plans, which exceeded 255.5.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This newly hired staff person incorrectly opened a release of information packet in our electronic record system that is no longer in use by our Program. Client #11 will be seen on 10/30/19 and his consent form packet will be updated. By 11/4/2019, The clinical supervisor will conduct a training to remind all staff to only use the MATP Complete Consents and Release packet. The clinical supervisor will monitor ongoing compliance with this standard by verifying the correct packet prior to applying a supervisory signature. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to document an emergency contact, prior to the administration of a narcotic agent, in one of eleven client records reviewed.
Patient #9 was admitted on January 28, 2019 and was active at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #9 did sign a emergency contact consent form for his sister on 1/28/2019. By 11/8/19 staff will receive training on the timely completion of emergency consents forms. The clinical supervisor will be responsible for conducting the training. The clinical supervisor will also be responsible for monitoring compliance with the standard via a careful review of emergency release forms prior to a applying supervisory sign-off.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) 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 seven of eleven patient records reviewed.
Patient #2 was admitted on February 28, 2019 and was active at the time of inspection. A treatment plan update was completed on December 14, 2018 and the next update was due no later than February 14, 2019. However, the update was not completed until March 25, 2019. Additionally, another treatment plan update was completed on March 25, 2019 and the next update was due no later than May 25, 2019. However, the update was not completed until June 19, 2019. Finally, another treatment plan update was completed on June 19, 2019 and the next update was due no later than August 19, 2019. However, the update was not completed until September 11, 2019.
Patient #4 was admitted on May 26, 2015 and was active at the time of inspection. A treatment plan update was completed on August 5, 2019 and a treatment plan update was due no later than October 5, 2019. However, the update was not completed at the time of inspection.
Patient #6 was admitted on May 27, 2003 and was discharged February 27, 2019. A treatment plan update was completed on December 3, 2018 and the next update was due no later than February 3, 2019. However, the update was not completed until February 13, 2019.
Patient #8 was admitted on February 28, 2019 and was active at the time of inspection. A treatment plan update was completed on April 10, 2019 and the next update was due no later than June 10, 2019. However, the update was not completed until June 28, 2019. Additionally, another treatment plan update was completed on June 28, 2019 and the next update was due no later than August 28, 2019. However, the update was not completed until September 6, 2019.
Patient #9 was admitted on January 28, 2019 and was active at the time of inspection. A treatment plan update was completed on May 6, 2019 and the next update was due no later than July 6, 2019. However, the update was not completed until July 16, 2019. Additionally, another treatment plan update was completed on July 16, 2019 and the next update was due no later than September 16, 2019. However, the update was not completed until October 1, 2019.
Patient #11 was admitted on July 3, 2018 and was discharged March 22, 2019. A treatment plan update was completed on September 17, 2018 and the next update was due no later than November 17, 2018. However, the update was not completed until January 1, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff training will be provided by the clinical supervisor to assist counselors to improve the timely documentation of treatment plan updates. The clinical supervisor will monitor compliance by reviewing treatment plan Alerts in carelogic prior to the end of each month. The training will take place on 10/31/19. The treatment plan update for client #4 was updated on 10/22/19.The procedure for ensuring the timeliness will occur by looking into each record's alert system for incomplete documentation. The supervisor will preform this duty as part of routine supervision. |