INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18, 2022 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 2021 through October 2022 fire drill log, the facility failed to ensure that their written fire drill log included the amount of time it took for evacuation, the time of the drill, and the number of persons in the facility at the time of the drill.
The July 2022 drill log did not document the time of the drill or the number of persons in the facility at the time of the drill. Additionally, the December 2021, January 2022, February 2022, May 2022, August 2022, and October 2022 drill logs did not document the number of persons in the facility at the time of the drill. Also, the March 2022, April 2022, June 2022, and September 2022 drill logs did not document the number of persons in the facility at the time of the drill or the amount of time it took for evacuation.
This is a repeat citation from the December 1, 2020 and November 15, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Fire Drill Log will be revised to include all required elements by 12/9/2022. The Plant Operations Team will be educated on the new form by 12/31/22. The Plant Operations Director or delegate will review all Fire Drill Logs following each drill for completeness. |
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 obtain an informed and voluntary consent to release information form prior to the disclosure of information in three of seven client records reviewed.
Client #1 was admitted on November 12, 2022 and was active at the time of 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 #2 was admitted on November 10, 2022 and was active at the time of 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 #3 was admitted on November 5, 2022 and was active at the time of 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.
This is a repeat citation from the December 1, 2020 and November 15, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Release of Information Authorizations for the funding source were obtained for Clients 1, 2, and 3 on 11/18/2022. The Director of Admissions standardized obtaining a Release of Information for the funding source on 12/6/22. The Case Managers received direction from the Director of Social Services on 12/5/22 to check the chart for the completed release before releasing any information to the funding source.
To ensure compliance with standard 709.28,100% of admissions to the DDAP licensed service between 12/6-12/31/22 will be audited for a completed Release of Information to the funding source by the Director of Social Services. Any omissions will be immediately addressed and staff education will be provided as needed. Audits will be tracked and reported to the Project Director on 12/31/22.To support ongoing compliance, beginning 1/1/2023, ten charts per month will be audited by the Director of Social Services until 100% compliance with this standard is achieved for 3 consecutive months. Audit results will be reported monthly in Quality Council. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for obtaining an informed and voluntary consent to release information form prior to the disclosure of information were submitted and approved by the Department for the November 15, 2021 and December 1, 2020 annual licensing inspections. Obtaining an informed and voluntary consent to release information form prior to the disclosure of information was again found to be a deficiency in the November 18, 2022 licensing inspection.
Plans of correction for ensuring that the written fire drill log included the amount of time it took for evacuation and the number of persons in the facility at the time of the drill were submitted and approved by the Department for the November 15, 2021 and December 1, 2020 annual licensing inspections. Ensuring that their written fire drill log included the amount of time it took for evacuation and the number of persons in the facility at the time of the drill was again found to be a deficiency in the November 18, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An analysis was conducted to identify the root cause for failure to follow both plans of correction. Based on this analysis, the Project Director will conduct monthly audits of the Plans of Correction starting January 2023 and report findings to Quality Council. Quality Council will act as the POC monitor and recommend actions to the CEO or Governing Board should there be concerns that Plans are not being followed. |