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 September 18-21, 2023, to determine compliance with the requirements of the 42 CFR Part 441, Subpart D Regulations for Emergency Preparedness in Psychiatric Residential Treatment Facilities. The census during the survey was eight and the sample consisted of four residents.




Plan of Correction:




441.184(a)(4) STANDARD
Local, State, Tribal Collaboration Process

Name - Component - 00
403.748(a)(4), 416.54(a)(4), 418.113(a)(4), 441.184(a)(4), 460.84(a)(4), 482.15(a)(4), 483.73(a)(4), 483.475(a)(4), 484.102(a)(4), 485.68(a)(4), 485.542(a)(4), 485.625(a)(4), 485.727(a)(5), 485.920(a)(4), 486.360(a)(4), 491.12(a)(4), 494.62(a)(4)

[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:]

(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. *

* [For ESRD facilities only at 494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.

Observations:

Based on a review of the facility emergency preparedness plan (EPP) and interview, it was determined that the facility failed to ensure that the EPP included documentation of the facility efforts to contact, cooperate, and collaborate with emergency preparedness officials (local, tribal, regional, state, federal) in order to facilitate an integrated response during a disaster situation. This applied to all individuals that resided at the facility. Findings included:

Review of facility EPP was completed on September 21, 2023. This review failed to reveal documentation that local, tribal, regional, state, or federal emergency officials were contacted and coordinated with regarding the facility's needs during an emergency or disaster.

Interview conducted with the director of human resources on September 21, 2023, at 9:57 AM, confirmed that documentation of the facility's efforts to contact, cooperate, and collaborate with emergency preparedness officials was missing from the facility's EPP.











Plan of Correction:

The Director of Facilities Management/Agency Safety Officer has been in contact with the local EMA (10/6/23) to establish formal collaboration protocols. A formal Memorandum/Agreement of understanding will be developed and signed by both parties. These agreements will be established with each local EMA for all Agency Locations in order to ensure safety protocols for all residents. This agreement will be shared with and managed by the Agency's Safety Committee, with copies provided to the Director of Residential Services. These agreements will be reviewed by the Safety Committee annually and upon completion of the annual Emergency Preparedness Drill/ tabletop Exercise. Progress on this action will be monitored by the designated Safety Officer, the Director of Residential Services and the members of the Agency Safety Committee. Adherence to this plan will be determined based on complete/executed plans being filed. All actions will be completed by 4/1/24.




441.184(b) STANDARD
Development of EP Policies and Procedures

Name - Component - 00
403.748(b), 416.54(b), 418.113(b), 441.184(b), 460.84(b), 482.15(b), 483.73(b), 483.475(b), 484.102(b), 485.68(b), 485.542(b), 485.625(b), 485.727(b), 485.920(b), 486.360(b), 491.12(b), 494.62(b).

(b) Policies and procedures. [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 every 2 years.

*[For LTC facilities at 483.73(b):] Policies and procedures. The LTC facility 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.

*Additional Requirements for PACE and ESRD Facilities:

*[For PACE at 460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years.

*[For ESRD Facilities at 494.62(b):] Policies and procedures. The dialysis facility 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 every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area.

Observations:


Based on a review of facility provided documentation, emergency preparedness plan (EPP), and interview, it was determined that the facility failed to ensure emergency preparedness policies and procedures, based upon the EPP and risk assessment, were reviewed and updated at least every two years. This applied to all individuals that resided at the facility. Findings included:

Review of facility provided documentation and EPP was completed on September 21, 2023. This review failed to reveal documentation to indicate that the facility had reviewed and updated the EPP at least every two years.

Interview conducted with the director of human resources on September 21, 2023, at 10:00 AM, confirmed that the facility failed to review and update the EPP at least every two years.











Plan of Correction:

The Agency Safety Committee will review all current plans during the November 2023 meeting. During this meeting a date for annual review of plans will be established. Each year, local Emergency Management Agencies will be provided with these updated plans, with formal memorandum/agreements with local EMA's updated to acknowledge receipt of the updated plans. The Agency Safety Committee will maintain copies of these agreements and also provide a copy to the Director of Residential Services as they are executed. The agency will assure that this corrective plan is applied to all Agency facilities. Minutes from the safety minutes will be reviewed monthly by the Director of Residential Services and Safety Officer to ensure adherence to this plan. This corrective action will be accomplished by 4/1/24 and demonstrated by documentation of the Emergency Preparedness Plan review within the Safety Committee meeting minutes.


Initial Comments:

A validation survey was conducted September 18-21, 2023, to determine the compliance with the requirements of 42 CFR Part 483, Subpart G Regulations for Psychiatric Residential Treatment Facilities. The census during the survey was eight and the sample consisted of four residents.





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 provided staff training records and interview, it was determined that the facility failed to ensure that all staff were trained and demonstrated competencies in safe crisis management (SCM) on a semiannual basis. This applied to two of 25 staff training records reviewed. Findings included:

A review of facility provided staff training records for 25 staff was completed September 19, 2023. This review revealed that one staff had been trained on SCM on March 20, 2023, however, the previous training occurred on July 2, 2022. This review revealed a second staff had been trained on SCM on February 20, 2023, however, the previous training occurred on July 26, 2022.

An interview was conducted with the director of human resources (DHR) on September 19, 2023, at 10:44 AM. At this time, the DHR confirmed that the two staff had not been trained on SCM on a semiannual basis.









Plan of Correction:

Both of the identified staff completed SCM on 9/19/23. Moving forward, training compliance will be reported out during monthly Program Manager group supervision. Identified training deficiencies will be reviewed during monthly individual supervision with each Program Manager. The Director of Residential Services will document the results of individual and group supervision in a conference note to include notification of those with pending training deadlines, identified deficiencies, and timelines for correction. Professional Development Specialists and Agency Certified SCM Trainers will be consulted and will assist in achieving training compliance. The Director of Residential Services will implement and monitor this corrective action, which will be accomplished by 4/1/24. Corrective action will be evidenced by achievement of 100% training compliance as noted in the employee record via the Relias system.