INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 8, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, UPMC Western Behavioral Health at Safe Harbor 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) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of fire drill records, the facility failed to conduct unannounced fire drills once a month.
Reviewed fire drills from March 2023 to January 2024. No fire drills were conducted during the months of March 2023 and November 2023.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Program Director will ensure that DDAP licensure code Fire Safety 705.28(d) is conducted on a monthly basis, unannounced to staff, during normal staffing conditions, and logged on Safe Harbor Addiction Medicine Fire Drill forms.
Program Director has scheduled fire drills out for the year of 2024 and has developed a tracking system to ensure fire drills are completed each month, on different days and times.
|
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 on a review of fire drill records, the facility failed to maintain a written fire drill record that included all regulatory information.
Reviewed fire drill records from March 2023 through January 2024. The completed fire drill records were missing the following information: June 2023 did not include exit route used, October 2023 did not include problems encountered, and whether fire alarm or smoke detector was operative.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Program Director will ensure that DDAP licensure code Fire Safety 705.28(d) is conducted on a monthly basis, unannounced to staff, during normal staffing conditions, and logged on Safe Harbor Addiction Medicine Fire Drill log form where date, time to evacuate, exit route, number of individuals in the facility are counted and logged, problems encountered is noted, and if fire alarms and smoke alarms are working properly.
Program Director has updated the Safe Harbor Addiction Medicine Fire Drill form to include two sign-off signatures to ensure there is a check and balance.
Program Director also added a check box on the form that will indicate if there are no problems encountered.
Fire Drill Logs are turned into Executive Assistant, who will sign off on fire drills after Program Director completes the initial form to ensure all identified areas are fill out correctly.
|
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 one of seven records.
Client #5 was admitted August 15, 2023 and still a current client. There was no consent to release information form for probation. There was confirmed disclosure in client record that the facility contacted probation on September 27, 2023.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 14, 2023 licensing renewal inspection.
|
Plan of Correction
Program Director will educate staff by 3/1/24 and reviewed the specifics of the records of release citation. Staff will also be educated by 3/1/24 on 709.28 Confidentiality. Once AMS OP Staff have been trained, they will sign off documenting the education/training efforts.
AMS OP staff will obtain complete releases of information prior to disclosure of client records.
This element will be incorporated into the Program Directors monthly chart audits, which are part of the quality assurance committee's monthly reporting.
|
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in three of seven records.
Client #2 was admitted on August 29, 2023 and discharged December 26, 2023. A treatment plan was completed on August 29, 2023 and the next update was due no later than October 28, 2023; however, the next update was completed on November 9, 2023.
Client #3 was admitted on August 3, 2023 and discharged January 18, 2024. A treatment plan was completed on August 3, 2023 and the next update was due no later than October 2, 2023; however, it was completed on December 6, 2023.
Client #5 was admitted on August 15, 2023 and still a current client. A treatment plan update was completed on October 13, 2023 and the next update was due no later than December 12, 2023; however, it was completed on January 3, 2024.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 14, 2023 licensing renewal inspection.
|
Plan of Correction
Program Director will review requirements with outpatient staff to ensure reviews are completed every 60 days so that DDAP licensure code7 09.92(b) if being carried out. This will be completed no later than 3/1/24.
AMS OP Staff will utilize AMS Case Load report as a tool to ensure they know when treatment plans were last completed and when they are due. AMS OP Staff will complete treatment plans reviews even if the individual in services is not present. AMS OP Staff will be trained on this element by 3/1/24. Once AMS OP Staff have been trained they will sign off documenting the education/training efforts.
Program Director will monitor this charting element in monthly audits, which are then reported to the Quality Assurance Committee and will be reviewed for future clients.
|
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to complete case consultations according to agency policy and procedure manual timeframes in three out of seven applicable records reviewed.
Agency P&P states each client's progress is reviewed at least once quarterly via case consultation in a multi-disciplinary or peer team. Case consultation can be held more often if need be and may be held annually for clients who are in treatment beyond one year.
Client #5 was admitted August 15, 2023 and still a current client. Client #5 case consultation was due by November 13, 2023 but not completed at the time of the inspection.
Client #6 was admitted on October 16, 2023 and still a current client. Client #6 case consultation was due by January 18, 2024 but not completed at the time of the inspection.
Client #7 was admitted on August 7, 2023 and still a current client. Client #7 case consultation was due by November 6, 2023 but not completed until January 19, 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Director will update AMS Case Load report to ensure that Case Consults are being completed as the Addiction Medicine Guidelines indicate, on a quarterly basis. This element has been completed effective 2/19/24.
Program Director will review requirements with AMS OP staff to ensure that case consult reviews are completed quarterly so that DDAP licensure code 709.93(a)(8) is being carried out.
AMS OP Staff will utilize AMS Case Load report as a tool to ensure they know when case consultations were last completed and when they are due. AMS OP Staff will be trained on this element by 3/1/24. Once AMS OP Staff have been trained they will sign off documenting the education/training efforts.
Program Director will monitor this charting element in monthly audits, which are then reported to the Quality Assurance Committee and will be reviewed for future clients.
|