QA Investigation Results

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


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Initial Comments:

A validation survey was conducted October 9-11, 2018, to determine compliance with the requirements of the 42 CFR Part 483, Subpart D Requirements for Emergency Preparedness in Psychiatric Residential Treatment Facilities. There were no deficiencies.




Plan of Correction:




Initial Comments:

A validation survey was conducted October 9 - 11, 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 seven and the sample consisted of four individuals.



Plan of Correction:




483.376(f) ELEMENT
EDUCATION AND TRAINING

Name - Component - 00
Staff must demonstrate their competencies as specified in paragraph (a) of this section on a semiannual basis and their competencies as specified in paragraph (b) of this section on an annual basis.


Observations:

Based on a review of facility training records and record reviews, it was determined that the facility failed to ensure all staff participating in restraints are current with safe crisis management (SCM) training. This applied to two staff. Findings included:

A review of staff training records was completed on October 11, 2018. This review revealed that two staff were out of compliance with their semi annual SCM training. Further review of restraint records revealed that on October 3, 2018, these two staff participated in a restraint with Individual #4.

Interview with the director of residential on October 11, 2018, at 9:35 AM confirmed that the two staff were not current with their semi annual SCM training when participating in the restraint with Indivual #4 on October 3, 2018






Plan of Correction:

During the site visit, it was discovered there was both human, as well, as system error in the Human Resources Department. The Human Resources staff were trained by the Director of Human Resources on October 10th. 11th, and 12th on the correct way to input training dates, as well as due dates, for Safe Crisis Management into the system. Additionally, the Human Resources Department has been problem solving without a support team from RELIAS, where we house all of our training information.
In the mean time, the program ran individual reports and cross referenced them with sign in sheets for all staff in the programs. The two staff found to be out of compliance were informed immediately. Those two staff both completed Safe Crisis Management Training- Non-Physical on Monday, 10/15/18 and completed Safe Crisis Management on Thursday, 10/18/18.
We are confident with the training that occurred in the Human Resources Department and manually tracking trainings, this error will not occur again. This will be monitored by the Human Resources Director. This will be monitored by the Human Resources Director monthly by reviewing and running reports in the RELIAS System. The program will then cross reference the reports with the manual tracking sheets to ensure each staff is in compliance and signs up timely for upcoming trainings.