INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 13, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Emergency Behavioral Health Walk-In 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:
|
Plan of Correction
|
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.
|
Observations
Based upon the review of March through October 2025 fire drill logs, the facility failed to document the exit route used and number of persons in the facility at the time of the drill in all logs reviewed.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
POC: The Facility has an established policy and process for completion of fire drills. Until July of 2025, the Facility did not have access to the building fire panel as it is shared with the co-tenants of the building. The Facility was in contact with the co-tenants and the building landlord during that time to obtain needed access to the fire panel. The Facility will review the established policy and process to ensure no updates need to be made and review with leadership. Monitoring: The Facility has established an oversight monitoring process to ensure fire drills are completed per policy and regulation. During Organization Safety Committee meetings, the Facility's Risk & Quality Specialist will share a report out of the conducted fire drills each quarter and solicit feedback from the committee. This practice will ensure the routine conduction of fire drills with regulatory and facility policy. Responsible Person/Department: Risk & Quality Specialist Full Compliance with Regulation: The Facility will be in full compliance with regulation and standard conduction of fire drills by the end of Q1 2026 (March 31, 2026). |
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.
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to disclosure of information in six out of seven records reviewed. The client records did not have a consent form for the funding source.
Client #1 was evaluated for services on June 10, 2025.
Client #3 was evaluated for services on August 4, 2025.
Client #4 was evaluated for services on July 22, 2025.
Client #5 was evaluated for services on September 15, 2025.
Client #6 was evaluated for services on July 29, 2025.
Client #7 was evaluated for services on September 4, 2025.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
POC: The Facility is in the process of implementing a new standard release form which will include written consent related to disclosure of SUD information including information disclosure for billing, referrals, and operations. This form will be completed with the client during the admission process. Monitoring: The newly implemented form will be completed as a standard part of the admission process, in which, the Facility's EHR system can bundle all required admission forms together. The Compliance team monitors changes to regulations and updates forms accordingly. Responsible Person/Department: Compliance Department Full Compliance with Regulation: The Facility will be in full compliacne with regulation regarding consent to disclose information by the end of Q1 2026 (March 31, 2026). |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on the review of client records, the facility failed to inform the client that they may not be discriminated against based on creed, sex, ethnicity and color in seven out of seven records reviewed.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
POC: While our client welcome packet includes the required non-discrimination statement, the following non-discriminatory clauses are not currently present: creed, ethnicity, or color. The Facility will update the client welcome packet to include all non-discriminatory clauses ensuring all clients are properly informed of their non-discriminatory rights. Monitoring: The Compliance team monitors changes to regulations and updates forms accordingly. Responsible Person/Department: Compliance Department Full Compliance with Regulation: The Facility will be in full compliance with regulation regarding consent to disclose information by the end of Q1 2026 (March 31, 2026). |