INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 30, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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(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
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of eights client records reviewed.
Client #1 was admitted on March 5, 2021 and was discharged on June 24, 2021. The comprehensive treatment plan was completed on March 5, 2021 and the first update was due no later than May 5, 2021. However, the treatment plan update was not completed prior to the client's discharge.
Client #4 was admitted on March 30, 2021 and was discharged on August 10, 2021. A treatment plan update was completed May 4, 2021 and the next update was due no later than July 4, 2021. However, there was no treatment plan update completed prior to the client's discharge.
Client #6 was admitted on April 28, 2021 and was still active at the time of inspection. A treatment plan update was completed July 7, 2021 and the next update was due no later than September 7, 2021. However, there was no treatment plan updated completed at the time of inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Date to be Completed by: 10/14/21
Responsible Party: Program Director
Actions:
- The Program Director reviewed the policy and procedure regarding treatment plans and updates. The outcome of the review indicated the policy and procedure met the intent of the standards; no changes required.
- The Program Director provided staff education to staff including counselors (and team) regarding the treatment plan policy and expectations in alignment with 711.92(d) LICENSURE Treatment Plan Update. Initial treatment plan is completed upon admission and is the working Treatment Plan for first 30 days of patient's treatment; treatment plan updates occur at least every 60 days thereafter, and/or after any significant change/event in the patient's course of treatment. Education of staff occurred on 10/1/21. Completion of the training was documented in the staff members' personnel records.
- As outlined in their role expectations and counselor training, counselors are responsible for verifying that patients assigned to them have treatment plan updates completed according to standards. Counselors developed a plan to assist with a reminder system in the electronic medical record (EMR) so that they do not miss dates for updates. Updates are individualized to meet patient needs and the new reminder system will facilitate the required frequency for treatment plan updating to be met. Counselors began implementing this process after training occurred on 10/14/2021. Completion of the training was documented in the staff members' personnel records.
- If patient disengages in program when treatment plan is due, note will be placed in chart regarding patient non-participation for treatment plan update.
- Patient records noted in findings are either discharged patients and/or for other reasons cannot be updated. To prevent a re-occurrence, the staff were retrained, and procedures were put into place as outlined above for future documentation compliance. Staff education was completed on 10/1/21. Completion of the training was documented in the staff members' personnel records.
Ongoing Compliance:
- Program Director assigned counselors monthly chart auditing responsibilities to verify adherence to standard during the review period. Five percent (5%) of charts or 20 charts/month, whichever is greater, will be audited for Treatment Plan compliance until three months of sustained compliance is achieved.
- Program Director or her designee will report results of compliance audits to the PPMC Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight.
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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
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in one of eight client records reviewed.
Client #3 was admitted on September 5, 2019 and was discharged July 29, 2021. There was an informed and voluntary consent form to the funding source, signed and dated by the client on September 5, 2019, which expired on September 5, 2020. There was documentation of billing after the expiration date and there was no updated consent form signed by the client documented in the record prior to the disclosures.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Date to be Completed by: 10/31/21
Responsible Party: Responsible Party: Program Director
- Program Director reviewed POLICY 9.0 - CONFIDENTIALITY, and the related Consent to Release of Information form. Completed 10/1/2021. The review revealed an opportunity to re-educate unit staff on the procedures outlined in the policy.
- Program Director provided program staff with reeducation surrounding standards of confidentiality and release of information (POLICY 9.0-CONFIDENTIALITY) to verify that the patient or authorized representative have provided a consent to release of information to outside referrals/ resources including funding sources prior to release of confidential information in accordance with 28 Pa Code 71l. 93(c). Program Director advised staff that consents to release information are to be in patient's record before any information may be provided. Staff education was completed on 10/1/21. Completion of the training was documented in the staff members' personnel records.
- Consent for Release of Information form has been updated in electronic medical record (EMR) to allow a hard stop in the system so that the correct consent to release of information is applied at the correct timeframe. Implementation and training to be completed by 10/31/21.
- Consents for release of information explicitly indicate expiration date in EMR. Consents for release of information indicate "active", "expired" or "revoked" status in EMR.
- Training was conducted by the Program Director to counselors regarding time limits of releases of information, limits of what can be released and how information can be released based on consent for release of information form; training will be conducted with staff utilizing forms (counselors and staff performing admission paperwork). Staff education to be completed by 10/31/21. Completion of training to be documented in the staff members' personnel records.
- Patient records noted in findings are either discharged patients and/or for other reasons cannot be updated. To prevent a re-occurrence, the staff were retrained and procedures were put into place as outlined above for future documentation compliance. Education was completed on 10/1/21. Completion of the training was documented in the staff members' personnel records.
- Program Director assigned counselors monthly chart auditing responsibilities to verify adherence to standard during the review period. Five percent (5%) of charts or 20 charts/month, whichever is greater, will be audited for Consent to Release Information form compliance until three months of sustained compliance is achieved.
- Program Director or her designee will report results of compliance audits to the PPMC Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight
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711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
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:
(ii) The specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document specific information to be disclosed on consent to release information forms in one of eight client records reviewed. Additionally, the facility failed to keep consent to release information forms within the limitation requirements of 4 Pa. Code 255.5 in two of eight client records reviewed.
Client #2 was admitted on May 3, 2021 and was discharged on August 5, 2021. There were consent to releasee information forms to a urinalysis lab and a transportation company, signed and dated by the client, that did not document the specific information to be disclosed.
Client #7 was admitted on June 17, 2021 and was still active at the time of inspection. There was a consent to release information form to the funding source, signed and dated by the client on June 17, 2021, that allowed for the release of medical, psychiatric, HIV/AIDS and diagnoses, all of which exceeded the limits established by 4 Pa. Code 255.5.
Client #8 was admitted on July 8, 2021 and was still active at the time of inspection. There was a consent to release information form to the funding source, signed and dated by the client on July 8, 2021, that allowed for the release of medical, psychiatric, HIV/AIDS and diagnoses, all of which exceeded the limits established by 4 Pa. Code 255.5.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Date to be Completed by: 10/31/21
Responsible Party: Responsible Party: Program Director
- Program Director reviewed POLICY 9.0 - CONFIDENTIALITY, and the associated Consent to Release of Information form. Completed 10/1/2021. The review revealed an opportunity to re-educate unit staff on the procedures outlined in the policy.
- Program Director provided program staff with reeducation surrounding standards of confidentiality and release of information (POLICY 9.0-CONFIDENTIALITY) to verify that the patient or authorized representative have provided a consent to release of information to outside referrals/resources including funding sources in accordance with 28 Pa Code 71l. 93(c). Program Director advised staff that consents to release information are to be in patient's record before any information may be provided. Staff education was completed on 10/1/21. Completion of the training was documented in the staff members' personnel records.
- Consent for Release of Information form has been updated in electronic medical record (EMR) to allow a hard stop in the system so that the correct consent to and release of information is applied at the correct time and with the correct information which will reduce opportunity for incidents surrounding release of information that is inconsistent with the standard. Implementation and training to be completed by 10/31/21.
- Consents for release of information explicitly indicate expiration date in EMR. Consents for release of information indicate "active", "expired" or "revoked" status in EMR.
- The Program Director conducted training regarding time limits of releases, limits of what can be released and how information can be released per standard. The counselors and staff performing admission paper-work will be trained on the current updated consent form. b
- Patient records noted in findings are either discharged patients and/or for other reasons cannot be updated. To prevent a reoccurrence, the unit staff were retrained and procedures were put into place as outlined above for future documentation compliance. Staff education was completed on 10/1/21. Completion of the training was documented in the staff members' personnel records.
- Program Director assigned counselors monthly chart auditing responsibilities to verify adherence to standard during the review period. Five percent (5%) of charts or 20 charts/month, whichever is greater, will be audited for Consent to Release Information form compliance until three months of sustained compliance is achieved.
- Program Director or her designee will report results of compliance audits to the PPMC Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight
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