INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on October 17-19, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Center for Behavioral Health - Ha Inc. 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) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
The findings include:
The fire drill logs for the fire drills conducted from November 2011 - September 2012 were reviewed on October 17, 2012. All of the fire drills conducted during that time period took place between 11:30 AM and 1:50 PM. There were no clients in the building during any of the fire drills, with the exception of 7/31/12, which included 1 client. The facility currently has a census of 438 clients.
No additional information was provided by the facility director or clinical supervisor to document that any additional fire drills were conducted at different times of the day.
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Plan of Correction
The Program Director met with members of the Management Team and the Health and Safety Captain to review the Division of Drug and Alcohol Program Licensure citations received during the licensing inspection. The Program Director reviewed how past fire drills were conducted and any barriers. A plan was developed to conduct unannounced drills during medicating and clinic hours. Which are between 5:00 a.m. to 2:00 p.m., on different days of the week, at different times of the day and on different staffing shifts to capture times when patients are present in the clinic. A clinical staff meeting was held to inform all Associates of the citations and our Plan of Correction. The Program Director will insure that the Plan of Correction is followed and the proper information is documented in the fire drill log. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in three of three client records.
The findings include:
Eight discharged client records were reviewed on October 17-19, 2012. Three of the discharged clients reviewed were successfully discharged and required an aftercare plan. Client records # 15, 16 and 17 did not include documentation of an aftercare plan.
Client #15 was admitted to treatment on February 3, 2009 and successfully discharged on August 3, 2012. There was no documentation of an aftercare plan in client record #15.
Client #16 was admitted to treatment on December 28, 2005 and successfully discharged on April 13, 2012. There was no documentation of an aftercare plan in client record #16.
Client #17 was admitted to treatment on March 13, 2008 and successfully discharged on March 5, 2012. There was no documentation of an aftercare plan in client record #17.
An interview with the clinical supervisor took place on October 19 , 2012 at which time it was confirmed that there was no documentation of an aftercare plan in client records #15, 16 and 17.
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Plan of Correction
The Program Director met with the Clinical Supervisors to review the Division of Drug and Alcohol Program Licensure citations received during the licensing inspection. The Program Director review Aftercare Plans and the proper documentation of the Aftercare Plan. A Clinical Staff meeting was held to review Aftercare Plans and documentation. The team was informed that discharged patients need to have an established aftercare plan done immediately prior to discharge. This aftercare plan should contain specific goals with target dates for completion, as well as referrals to additional treatment services/agencies. This will be monitored by the Clinical Supervisors. The Program Director will follow up with the Clinical Supervisors on a monthly basis. |