INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 1, an abbreviated off-site inspection, conducted on April 23, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.Based on the findings of Part 1, an abbreviated off-site inspection, Mercy Behavioral Health 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
|
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
|
Observations
The facility is publicly funded and failed to make available to the public the July 1, 2018 - June 30, 2019 annual report based on a review of the facility's administrative materials.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the May 2019 licensing inspection.
|
Plan of Correction
709.22 (c) As a publicly funded facility, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable. This annual report will be published and available to the public after June 30, 2020 for the fiscal year dated July 1, 2019 through June 30, 2020. Once published, the Facility Director will be responsible to insure the annual report is available for review for on-site license renewal inspection and that the Annual Report is completed each year ongoing by June 30 of each year.
The Annual Report will be Ambulatory Outpatient specific in content. The Annual Report will be created by the Outpatient Practice Administrator Team and the Communications Department under the Supervision of the Facility Director.
|