INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25-26, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, John F. Kennedy Behavioral Health 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:
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Plan of Correction
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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.
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Observations
A review of the September 2016 through September 2017 fire drill logs was conducted during the onsite inspection. Every log, except for the month of September 2017, failed to include the exit route used during the fire drill
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
P279
Beginning November 1, 2017, all fire drill logs will consistently include the exit route used during the drill. The clinical supervisor is responsible for documentation of each drill into the log. The clinical supervisor will complete a quarterly review of all unannounced fire drill logs to ensure this standard is consistently met. |
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 the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 3 of 8 client records.
Client #3 was admitted on 3/2/2017 and was an active client at the time of the inspection. There was a facsimile sent to a treatment provider on 3/8/17; however, there was no proper consent form on file prior to the disclosure of information.
Client #4 was admitted on 1/17/17 and was an active client at the time of the inspection. There was a facsimile sent to a treatment provider on 1/25/17; however, the facility did not obtain a proper consent to release form until 2/17/17.
Client #8 was admitted on 7/9/14 and was an active client at the time of the inspection. There was documentation that the facility had billed the funding source on 10/25/17 and 10/26/17; however, the consent form to the funding source on file expired 10/24/17. There were no updated forms in the record at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
0276
Staff will participate in a training to improve the timely completion of consent to release information forms for all clients. the clinical supervisor will be responsible for conducting the training. In addition, the consent forms for client #8 will be updated by his counselor on November 28, 2017. The clinical supervisor will also be responsible for monitoring compliance with the standard via weekly clinical record reviews, staff supervision, and review of staff case management logs.
effective 11/28/2017
effective 11/15/2017 |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the comprehensive treatment and rehabilitation plan in 1of 3 applicable client records failed to contain a client signature.
Client #3 was admitted on 3/2/17 and was still an active client at the time of the inspection. The comprehensive treatment plan was signed and dated on 3/30/17 by the counselor, but not the client; therefore, it appeared that the plan was created without the input of the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1875
Staff will participate in a training to improve the timely review and signing of the comprehensive treatment plan by our clients. The clinical supervisor will be responsible for conducting the training. The clinical supervisor will also be responsible for monitoring compliance with the standard via weekly clinical record reviews and staff supervision. Effective 11/15/2017 |