QA Investigation Results

Pennsylvania Department of Health
BEACON LIGHT BEHAVIORAL HEALTH SYSTEMS - SCHOOL ST.
Health Inspection Results
BEACON LIGHT BEHAVIORAL HEALTH SYSTEMS - SCHOOL ST.
Health Inspection Results For:


There are  4 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:


A validation survey was conducted August 6-8, 2018, to determine compliance with the requirements of 42 CFR Part 483, Subpart D Requirements for Emergency Preparedness in Psychiatric Residential Treatment Facilities. The census during the survey was eight individuals.




Plan of Correction:




441.184(b)(5) STANDARD
Policies/Procedures for Medical Documentation

Name - Component - 00
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:]

(5) A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

*[For RNHCIs at 403.748(b):] Policies and procedures. (5) A system of care documentation that does the following:
(i) Preserves patient information.
(ii) Protects confidentiality of patient information.
(iii) Secures and maintains the availability of records.

*[For OPOs at 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.

Observations:


Based on review of the facility emergency preparedness policy provided, it was determined that the facility failed to ensure that there was a system of medical documentation that preserves client information, protects confidentiality of client information, and secures and maintains availability of records. This applied to all the residents at the facility. Findings included:

A review of the facility's emergency preparedness policy and procedure manual was completed on August 7, 2018. This review failed to reveal a system of medical documentation that preserves client information, protects confidentiality of client information, and secures and maintains availability of records.

Interview with the vice president of facility management on August 7, 2018, at 1:45 PM, confirmed that there was no written policy to address preserving, securing and protecting client records during an emergency.






Plan of Correction:

The agency currently has a policy in the MIS Manual that addresses maintaining shadow records on clients. This policy will be updated to include details surrounding preserving the information in the event of an emergency requiring the need for relocation. This policy will also be updated to reflect additional documents that will be available in the shadow record. This update will be complete by 9/30/18. This policy will cover all programs and apply to all clients we serve. It will be monitored by John Pockey, Vice President of Facilities. This policy will be reviewed annually.


441.184(b)(8) STANDARD
Roles Under a Waiver Declared by Secretary

Name - Component - 00
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:]

(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

*[For RNHCIs at 403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Observations:

Based on a review of facility emergency preparedness policies and interview, it was determined that the facility failed to ensure their policy addressed the facilities role under a waiver declared by the Secretary of Health. Findings included:

A review of facility policies was completed on August 7, 2018. This review failed to reveal the role of the facility under a waiver from the Secretary of Health.

An interview was conducted with the vice president of facility management on August 7, at 2:20 PM. The plant operations director confirmed the facility had no policy in place to address the waiver as part of their emergency preparedness policy.








Plan of Correction:

A policy will be created by the Chief Risk Officer detailing our role in providing care at an alternate site in the event of the need to relocate clients due to an emergency. The policy will outline contacting the CMS office to allow our programs to operate at an alternative location, including our physicians who may be operating in a geography they are not actively licensed in. We will also include anticipated time frames we expect to return to normal operating functions, and expand upon our plan should that timeframe not be feasible. The policy will include a process for requesting this waiver on a pre-prepared document should be not have access to our network due to power outage. This policy will be completed by 9/30/18. This policy will cover all programs and apply to all clients we serve. It will be monitored by Becky Jensen, Chief Risk Officer. This policy will be reviewed annually.


441.184(c)(4)-(6) STANDARD
Methods for Sharing Information

Name - Component - 00
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following:

(4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care.

(5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under 484.102(c), CORFs under 485.68(c), and RHCs/FQHCs under 491.12(c).]

(6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4).

*[For RNHCIs at 403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative.

*[For RHCs/FQHCs at 491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4).

Observations:

Based on a review of facility emergency preparedness policies and interview, it was determined that the facility failed to ensure their policy addressed the facilities communication plan for sharing information and medical documentation with other health providers. Findings included:

A review of facility policies was completed on August 7, 2018. This review revealed the facility did not have a policy for sharing information and medical documentation with other health providers.

An interview was conducted with the vice president of facility management on August 7, at 2:20 PM. The plant operations director confirmed the facility had no policy in place to address the communication plan for sharing information and medical documentation with other health providers.







Plan of Correction:

An expansion to the current MIS policy regarding shadow files will also outline the communication plan to share medical information with other health providers to ensure continued care of clients in the event of an emergency and/or natural disaster. This will be updated by 9/30/18. This update will be complete by 9/30/18. This policy will cover all programs and apply to all clients we serve. It will be monitored by John Pockey, Vice President of Facilities. This policy will be reviewed annually.


Initial Comments:


A validation survey was conducted August 6-8, 2018, to determine compliance with the requirements of 42 CFR Part 483, Subpart G Requirements for Psychiatric Residential Treatment Facilities. The census during the survey was eight and the sample consisted of four individuals. There were no deficiencies.







Plan of Correction: