INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on Ridgeview Adolescent Behavioral Health Center at Pittsburgh by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, August 9-10, 2018 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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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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
The fire drill logs for the period of August 2017 - July 2018 were reviewed on August 9, 2018.
The facility failed to document the exit route used during fire drills as well as whether the fire alarm/smoke detector was operative.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, all fire door exits have been numbered. The exits used during fire drills will be documented on the fire drill record form. A notation will also be made that the fire alarms were activated when the fire drills occur. The completed fire alarm document will be reviewed by maintenance staff member performing the fire drill as well as Ridgeview's executive director. This will be monitored through November 30, 2018. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The facility failed to stay within the parameters of 4 Pa Code 255.5 when completing releases of information for government officials and payers.
Client records were reviewed on August 9-10, 2018. Client records #1, 2, 3, 4, 5 and 7 contained signed releases of information to governmental officials and payers that included the release of medication administration records, psychological assessment, psychiatric evaluation, treatment progress updates and medical history & physicals, all of which exceed the information permitted to be released to these entities.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective immediately, any items selected for release on a client release of information or consent will reflect only allowable items that fall within the parameters of 4 Pa Code 255.5. Staff completing consent forms will receive training by 9/21/2018. This process will be monitored by the clinical supervisor and/or clinical director through November 30, 2018. |