INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 28 - 29, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mercy Behavioral Health 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 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to document fire extinguisher training upon staff employment in two of two personnel records reviewed on March 28, 2018.
Employee # 7 was hired on January 31, 2018. Fire extinguisher training was not documented until March 21, 2018.
Employee # 8 was hired on November 24, 2017. Fire extinguisher training was not documented until March 5, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Adult Outpatient Program management staff have developed a new orientation training binder and added the fire extinguisher training sheet and an itemized training checklist page that this task item is to be done within the first week of hire. This orientation training binder will be updated and implemented for all new employees beginning 4/23/18 and direct supervisors are responsible for ensuring all task items are completed for new hires by their signature. |
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 document an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of eight client records reviewed on March 28 - 29, 2018.
The following client records contained written consents that exceeded 4 Pa. Code 255.5 by allowing for the release of the assessment, behavioral health notes, physician notes, psychiatric evaluation, medications, discharge summary, lab results, physical examination, treatment plan, psychological testing results, academic records, teacher observations and clinical summary.
Client # 2 was admitted on 11/28/17. The consent for probation was signed by the client during the intake process.
Client # 5 was admitted on 12/7/17. The consent for probation was signed by the client during the intake process.
Client # 8 was admitted on 12/15/17. The consent for a government agency was signed by the client during the intake process.
The findings were reviewed with staff during the licensing process.
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Plan of Correction
Pittsburgh Mercy has updated the Releases of Information to include what subsidies are held to 4 Pa. Code 255.5 during the last licensing review, which we believe has lead to the need to clarify which entities this code refers to and what content is allowed to be released. Pittsburgh Mercy Adult Outpatient Supervisors will go through training to better understand 4 Pa. Code 255.5 and the entities that are included in this restricted communication, as well as what information can and cannot be released during the 4/30/18 Outpatient Supervisors meeting. Supervisory staff will then be responsible for reviewing this information with their staff during their administrative staff meetings during the month of May 2018 to be completed by 5/31/18 and moving forward for all new staff during orientation training beginning 5/1/18. Training and handouts for ease of reference will be provided for all staff beginning 4/30/18 by Facility Director. |