INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 15, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Behavioral Wellness Center at Girard Return Program 1&2 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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705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a physical plant inspection conducted on August 15, 2024 between 12pm and 1pm, the facility failed to limit smoking to designated areas as the bathroom in client room #904 smelled strongly of cigarette smoke.
This is a repeat citation from the September 21, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
#Clinical Supervisors will continue enforce Policy :730.606 Tobacco Free Policy
a Responsible party ? Residential Clinical Supervisors and Support Staff (Addiction Recovery Assistant/Community Recovery Spec./Mental Health Works)
b. Completion date 8-27-24
#Nursing will provide participants with Nicotine Replacement Therapy (NRT) as needed
a Responsible party ? Nursing
b. Completion date 8-27-24
#Support staff will monitor participants ability to abide by Policy :730.606 Tobacco Free Policy
a Responsible party ? Residential
Clinical Supervisors and Support Staff (Addiction Recovery Assistant/Community Recovery Spec./Mental Health Worker)
b. Completion date 8-27-24
#Support staff will perform safety search of the participants and his/her belongings for contraband, Policy :730.413 Contraband and Policy: 730.412
a Responsible party ? Residential Clinical Supervisors and Support Staff (Addiction Recovery Assistant/Community Recovery Spec./Mental Heatlh Worker)
b. Completion date 8-27-24
#Staff will escort and monitor participants in designated outside smoking areas.
a Responsible party ? Residential Clinical Supervisors and Support Staff (Addiction Recovery Assistant/Community Recovery Spec./Mental Heatlh Worker))
b. Completion date 8-27-24 |
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 of client records, the facility failed to document the purpose of the disclosure on a consent to release information form in one of seven client records reviewed.
Client #4 was admitted on July 8, 2024 and was active at the time of inspection. The release of information form to a government agency was signed by the client on July 8, 2024, but the release form did not include the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
# Clinical supervisor will client # 4 with assigned counselor to discuss importance of documenting the purpose of the disclosure on consent forms
Responsible: Clinical Supervisor and Therapists
Date of completion: 09/18/24
2. Clinical Supervisor will provide a in-service training to all staff regarding the proper completion of consents and what triggers a need for a consents and purpose of the disclosure to prevent reoccurrence.
Responsible: Clinical Supervisor
Date of completion: 09/18/24
3.Clinical Supervisor will conduct random audits of five (5) charts per clinician each month to validate that staff members are correctly completing consent forms
Responsible: Clinical Supervisor
Date of completion: 09/18/24 |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document if a copy of a consent to release information form was offered to the client in one of seven client records reviewed.
Client #1 was admitted on July 17, 2024 and was still active at the time of the inspection. The release of information form to a social service agency was signed by the client on July 16, 2024; however, there was no documentation in the record indicating a copy of the release form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
# Clinical supervisor will client # 1 assigned counselor to discuss importance of ensure a copy of a consent to release information form was offered to the client and placed in their record in the future. Client# 1 ROI was completed prior to discharge with the assigned counselor.
Responsible: Clinical Supervisor and counselor
Date of completion: 09/18/24
# Clinical supervisors will provide supervision and an a in -service on consents requirements per DDAP regulation to prevent reoccurrence i.e. importance of ensure a copy of a consent to release information form was offered to the client and placed in their record.
Responsible: Clinical Supervisor
Date of completion: 09/18/24
# Clinical supervisor will review consent/ROI forms to assure forms contain required client offer of copy
on utilized form check box
Responsible: Clinical Supervisor
Date of completion: 09/18/24
# Clinical Supervisor will document outcome of consent audits in Performance Improvement report
Responsible: Clinical Supervisor
Date of completion: on-going
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709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's unusual incident report logs, the facility failed to notify the Department within 3 business days of an unusual incident following an event at the facility requiring the presence of police, fire, or ambulance personnel.
There was documentation that ambulance personnel were called to the facility on July 13, 2024; however, the incident was not reported to the Department until July 25, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
#Clinical supervisors will submit copies of all incident reports to the administrative assistant who will any DDAP required reports within three (3) business days. The administrative assistant will maintain a log of all DDAP incident reports submitted and monitor on a monthly basis
Responsible Parties:
Clinical Supervisor & Administrative Assistant
Date of Compliance: 9/18/24 |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation, during the intake and admission process, in three of seven client records reviewed.
Client #3 was admitted on July 1, 2024 and was active at the time of inspection. There was no psychosocial evaluation documented in the record at the time of the inspection.
Client #4 was admitted on July 8, 2024 and was active at the time of inspection. There was no psychosocial evaluation documented in the record at the time of the inspection.
Client #5 was admitted on December 5, 2023 and was discharged on January 10, 2024. There was no psychosocial evaluation documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
# Clinical supervisor will meet with client#3, #4 and #5 about following Policy :706.106 Bio-Psychosocial Assessment Process to prevent further reoccurrence of no psychosocial evaluation in clients'
record
Responsible: Clinical Supervisor and counselor
Date of completion: 09/18/24
#Clinical supervisor will conduct an assessment and identify all clinicians who struggle with writing an evaluative evaluation. Once these individuals are identified they will attend assessment and clinical formulation training on -site.
Responsible: Clinical Supervisor and counselor
Date of completion: 09/18/24
#Clinical Supervisor will conduct random audits of (5) charts per clinician each month to validate that staff is following Policy: 706.106 Bio-Psychosocial Assessment Process to prevent further reoccurrences of no psychosocial evaluation in client
Responsible: Clinical Supervisor
Date of completion: 09/18/24
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