INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 15, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Belmont Behavioral Hospital, LLC 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
Based on a review of the facility's December 2020 through October 2021 fire drill log, the facility failed to ensure that their written fire drill log included the amount of time it took for evacuation, the exit route used and the number of persons in the facility at the time of the drill.
The April 2021 drill log did not document the amount of time it took for evacuation, the exit route used and the number of persons in the facility at the time of the drill. Additionally, the February 2021, March 2021 and May 2021 drill logs did not document which exit route was used. Also, the December 2020, June 2021, July 2021 August 2021 and September 2021 drill logs did not document the exit route used and the number of persons in the facility at the time of the drill.
This is a repeat citation from the December 1, 2020 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The staff responsibility for Fire Drill documentation changed in October 2021. The new Plant Operations Director was educated about the requirements in 705.1 and October 2021 drill documentation was in compliance. |
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
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in three of nine client records reviewed.
Client # 2 was admitted on April 27, 2021 and was discharged on May 18, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 5 was admitted on October 28, 2021 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 9 was admitted on March 23, 2021 and was discharged on April 13, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This is a repeat citation from the December 1, 2020 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Re-education regarding the Funding Consent will be completed with all admissions counselors and clinical case managers by 12/15/2021. Monthly audits of 25 records for Funding Consents will continue until 100% compliance is achieved for three months. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency or organization to whom the disclosure is made on a consent to release information form in one of nine client records reviewed.
Client # 1 was admitted on September 25, 2021 and was discharged on September 29, 2021. The release of information form to an insurance provider was signed and dated by the client and witness on September 25, 2021; however, the form failed to document the name of the person, agency or organization to whom the disclosure would be made to.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Re-education regarding the Funding Consent will be completed with all admissions counselors and clinical case managers by 12/15/2021. Monthly Audits of 25 records for Funding Consents will continue until 100% compliance is achieved for three months. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to keep consent forms for the disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (a) for releases of information in one of nine client records reviewed.
Client # 7 was admitted on November 5, 2021 and was still active at the time of the inspection. There was a release of information form to a government agency, signed and dated by the client and witness on November 8, 2021, that allowed for the release of the aftercare plan, discharge summary and verbal treatment information, all of which exceeded the limits established by 4 Pa. Code 255.5.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client #7 was discharged from the hospital 11/29/2021. In order to ensure this disclosure does not occur again in the future, the Director of Social Services will educate all adult clinical case manager about the parameters for release of information as allowable by PA Code 255.5. Monthly Audits of 25 records for Authorizations to Disclose will continue until 100% compliance is achieved for three months.
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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review client records, the facility failed to document the purpose of the disclosure on a release of information form in one of nine client records reviewed.
Client # 1 was admitted on September 25, 2021 and was discharged on September 29, 2021. The release of information form to the emergency contact was signed and dated by the client on September 25, 2021, but the form did not document the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Re-education regarding the Authorizations to Disclose Information with attention to completeness will be completed with all admissions counselors and clinical case managers by 12/15/2021. Monthly Audits of 25 records for Authorizations to Disclose will continue until 100% compliance is achieved for three months. |
709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in one of nine client records reviewed.
Client # 7 was admitted on November 5, 2021 and was still active at the time of the inspection. The release of information form to the funding source was signed and dated by the witness on November 5, 2021, but the form did not document the dated signature of the client.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client #7 was discharged from the hospital 11/29/2021. Re-education regarding the Authorizations to Disclose Information with attention to completeness will be completed with all admissions counselors and clinical case managers by 12/15/2021. Monthly Audits of 25 records for Authorizations to Disclose will continue until 100% compliance is achieved for three months. |
709.28 (c) (6) 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. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event or condition upon which the consent will expire on consent to release information forms in two of nine client records reviewed.
Client # 1 was admitted on September 25, 2021 and was discharged on September 29, 2021. The release of information forms to the emergency contact and to the funding source were signed and dated by the client and witness on September 25, 2021, but both of the release forms failed to document the date, event or condition upon which the consent would expire.
Client # 3 was admitted on July 10, 2021 and was discharged on July 21, 2021. The release of information forms to the funding sources were signed and dated by the client and witness on July 10, 2021, but the forms failed to document the date, event or condition upon which the consent would expire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Re-education regarding the Authorizations to Disclose Information with attention to completeness will be completed with all admissions counselors and clinical case managers by 12/15/2021. Monthly Audits of 25 records for Authorizations to Disclose will continue until 100% compliance is achieved for three months. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's December 2020 through November 2021 unusual incident logs, the facility failed to file written unusual incident reports with the Department within 3 business days following incidents at the facility involving physical or sexual assaults by clients on February 18, 2021, April 7, 2021, May 18, 2021, July 21, 2021, July 29, 2021 and November 7, 2021.
This is a repeat citation from the December 1, 2020 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Belmont will retroactively submit all outstanding Incident Reports by 12/13/2021. The Compliance Officer and Risk Director reviewed regulations related to Incident Reporting (709.34). All incidents of assault will be reported out 11/30/21 moving forward. |