INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 26-27, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Stepping Stones @ Meadville 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on the review of the fire drill logs, the facility failed to document the evacuation time, exit route used, number of persons in the facility at the time of the drill and problems encountered.
The findings include:
The fire drill logs from October 2011 to September 2012 were reviewed on September 26-27, 2012. There was no documentation of the evacuation time, exit route used, number of person in the facility at the time of the drill and problems encountered for the months reviewed.
The Facility Director was interviewed on September 27, 2012 and confirmed the findings.
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Plan of Correction
Fire drill observation form had been inadvertently altered when documentation and forms system became electronic. Questions specific to this unit including the information noted in observation was removed during that process without unit staff or Project/Facility Director consent. Project Director communicated this to the Facility Engineering staff and Fire Marshal on Sept. 27 2012 with necessary items submitted to be re-included into the form at that time so that this information is captured for each fire drill. Form now amended to include necessary data. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the fire drill logs, the facility failed to document the alternative exit routes used during the fire drills.
The findings include:
The fire drill logs from October 2011 to September 2012 were reviewed on September 26-27, 2012. There was no documentation that facility used alternative exit routes during fire drills for the months reviewed.
The Facility Director was interviewed on September 27, 2012 and confirmed the findings.
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Plan of Correction
Fire drill observation form had been inadvertently altered when documentation and forms system became electronic. Questions specific to this unit including the information noted in observation was removed during that process without unit staff or Project/Facility Director consent. Project Director communicated this to the Facility Engineering staff and Fire Marshal on Sept. 27 2012 with necessary items submitted to be re-included into the form at that time so that this information is captured for each fire drill. Form now amended to include necessary data. |
157.23 (a) LICENSURE Patient records.
157.23 Patient records.
(a) In addition to the requirements contained in 115.32 (relating to contents), the patient's medical record shall contain a drug and alcohol support plan, follow-up information, and an aftercare plan, if applicable.
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Observations
Based on the review of patient records, the facility failed to document follow up information in two of two patient records.
The findings include:
Twelve patient records were reviewed on September 26-27, 2012. Four patient records were detoxification records. Per agency policy, follow up is to be completed at seven and thirty days. There was no follow up documented in patient records #3 and 4.
Patient # 3 was admitted on September 6, 2012 and discharged on September 11, 2012. Follow up was to be completed by September 18, 2012. There was no follow up documented.
Patient # 4 was admitted on July 27, 2012 and discharged on July 31, 2012. Follow up was to be completed by August 7, 2012 and August 31, 2012. There was no follow up documented.
The Facility Director was interviewed on September 27, 2012 and confirmed the findings.
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Plan of Correction
Policy governing this procedure was amended to reflect the fact that all patients,including those who leave against medical advice or are administratively discharged will also be contacted within 7 days. Staff oriented to system for keeping calls within the 7 days and no later. |
157.25 (b) LICENSURE Notification and termination.
157.25 Notification and termination.
(b) The patient shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of patient records, the facility failed to document that the patient had the opportunity to request reconsideration of the decision to terminate treatment in one of one patient record.
Twelve patient records were reviewed on September 26-27, 2012. Four patient records were detoxification records. One patient record reviewed was an involuntary termination.
Patient # 4 was admitted on July 27, 2012 and involuntarily discharged on July 31, 2012. There was no documentation that the patient was given the opportunity to request reconsideration of the decision to terminate treatment.
The Facility Director was interviewed on September 27, 2012 and confirmed the findings.
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Plan of Correction
The Letter of administrative discharge form is a notice given to the patient when they are to be administratively discharged from any level of the inpatient program. A note of the right to appeal the decision and area for patient to indicate whether they were requesting reconsideration, along with the titles of to whom they could appeal was added to the notice. The policy governing this process was amended to note this addition and staff were oriented to this. |