QA Investigation Results

Pennsylvania Department of Health
BEACON LIGHT BEHAVIORAL HEALTH SYSTEMS - WILLIAMS
Health Inspection Results
BEACON LIGHT BEHAVIORAL HEALTH SYSTEMS - WILLIAMS
Health Inspection Results For:


There are  6 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


An emergency preparedness survey was conducted January 9 - 10, 2018, to determine compliance with the requirements of the CFR 441.184 Requirements for Psychiatic Residential Treatment Faciltiy. There were no deficiencies.



Plan of Correction:




Initial Comments:

A validation survey was conducted January 9-10, 2018, to determine the 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.



Plan of Correction:




483.362(c) ELEMENT
MONITORING DURING AND AFTER RESTRAINT

Name - Component - 00
A physician, or other licensed practitioner permitted by the state and the facility to evaluate the resident's well-being and trained in the use of emergency safety interventions, must evaluate the resident's well-being immediately after the restraint is removed.



Observations:


Based on record reviews and interview it was determined that the facility failed to ensure that the post intervention assessments are completed by a licensed practioner permitted by the state. This applied to all four residents in the survey sample. Findings included:

Record reviews were completed for Individuals #1. #2, #3 and #4 on January 10, 2018, which result in 42 combined restraints reviewed. This review revealed that following each restraint the post intervention assessment was completed by a licensed practical nurse (LPN).

Interview with the director of residential services on January 10, 2018, at 9:00 AM confirmed that the above individuals were assessed by an LPN following a restraint. The director further confirmed that it is the facility's practice to utilize a LPN for these assessments.








Plan of Correction:

The Director of Residential Services and the Director of HealthCare Operations will ensure that there will be a qualified staff member on in the agency 24/7, in which a medical assessment following a restraint falls within their scope of practice. Monitoring nursing schedules across programs, as well as the on-call nursing calendar, will ensure that the deficient practice will not occur again. Each program director will review the restraint report, along with face to face documentation, to ensure that a qualified individual completed the assessment following the restraint. The Director of Residential Services and Director of HealthCare Operations will be responsible for monitoring the systematic changes.