INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 16, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Al-Assist Behavioral Health Care 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) (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.
|
Observations
Based on a review of the facility's August 2023 through July 2024 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts. There were twelve fire drills completed during the reviewed period and all of the fire drills were conducted prior to 2:12PM. The facility's posted hours of operation are Monday, Wednesday, Friday from 8:30AM to 5:00PM and Tuesday, Thursday from 8:30AM to 8:00PM. None of the fire drills were conducted during the Tuesday and/or Thursday evening hours of operation.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
In order to comply with standard 705.28(d(6)) on fire safety and fire drills being conducted on different days of the week, at other times of the day, and on various shifts, the following corrective action has been implemented:
A fire drill tracking form was developed to ensure fire drills are conducted during all shifts. Safety and Security Officers were trained on the fire drill tracker on July 26, 2024. The Safety and Security Officers were instructed to review the tracking form before performing the next fire drill to determine the day, date, and time of prior drills this calendar year to avoid date, day, or time patterns moving forward. The Safety and Security Officers must strategically plan fire and other safety drills to ensure various drills are placed during all shifts.
Safety and Security Officers are instructed to discuss only the pending monthly drill with the QA manager to ensure they comply with 705.28 (d)(6) before facilitating the drills.
The Quality Assurance Manager will monitor and track fire drill compliance monthly. The QA Manager will present the fire drill tracking form during site leadership meetings and provide the BH leadership with a quarterly summary of the fire drill report.
|
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.
|
Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in one of seven client records reviewed.Client #4 was admitted on November 28, 2023 and was discharged on February 16, 2024. There was a release of information form for a primary care physician and a release of information form for an emergency contact signed and dated by the client on November 28, 2023; however, the name of the person, agency or organization was not documented on either of the release forms. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction:
Plan of Correction:
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.
To comply with § 709.28 (c)(1) Confidentiality. An in-depth audit was conducted to determine the root cause of this infraction. Once the causal factors were identified, a full audit of all new members registered by the employee was conducted to determine if this infraction was widespread or limited. As a result of the findings, the employee was personally retrained on July 26, 2024, on regulation 709.28 Confidentiality, emphasizing (c)(1).
Additionally, on July 20, 2024, the audit findings were shared and discussed in detail during the monthly Registration Assistant meeting.
In addition, the Member Registration Completion Requirement policy was revised to state that no new member should be rushed through the registration process, Counselors must wait until the registration process is complete, and the Client Service Coordinator or Lead Registration Assistant, in the absence of the Client Service Coordinator must review the registration of new members upon completion to ensure compliance with § 709.28 before the member departs registration. The revised policy will be presented to the policy committee on August 13, 2024.
The Active member's informed and voluntary consent forms reviewed that failed to indicate the specific information about whom the information will be released have been asked to update consents to indicate name of the person, agency, or organization to whom a disclosure may be made.
Ongoing monitoring: DA clinical Supervisors/Coordinators will monitor active Clients to ensure all informed and voluntary consent forms comply. The Admission and Discharge Manager will perform bi-weekly audits of new admits, ensuring that the informed and voluntary consent forms are completed according to standards. The admission and discharge manager will present findings from the audit quarterly to the BH Leadership Team. |
709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
|
Observations
Based on review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days following a death or serious injury to due trauma, suicide, medication error or unusual circumstances. On May 16, 2024, the facility was notified of the off-site death of an active client. The facility did not report the incident to the Department as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
709.34 (c) (2) 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: (2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
To comply with standard 709.34 (c)(2) reporting of unusual incidents, a meeting was held with the Behavioral Health leadership team on July 19, 2024, to discuss reporting of unusual incidents to DAAP in addition to OMHSAS, and other required reporting entities. LicensingAlert 01-2024 was reviewed and discussed during this meeting.
The Behavioral Health leadership team is aware of the obligation to report unusual incidents and has informed their staff of the notification protocol. The unusual incident that the organization failed to report to DDAP according to protocol was submitted via email.
Since the audit, the site registration in the PA DDAP portal has been reset to permit the electronic submission of unusual incident reporting.
The unusual incidents reporting policy has been revised to include LicensingAlert 01-2024 instructions. The revised policy will be presented to the Policy Committee on August 13, 2024.
Unusual incident reporting will be monitored by the chief behavioral healthcare officer and site director at the time of incident occurrence to ensure full compliance with 709.34 (c)(2).
|