INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 7, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Chartiers Community Mental Health and Retardation Center, Inc. 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) (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.
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Observations
Based on a review of fire drill records between January 2020 and December 2021, the facility failed to document fire drills at least once a month.
Fire drills were not documented for the following months: January 2020, March - August 2020, October 2020, December 2020, March - April 2021, June 2021 - August 2021, October - November 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills were being conducted on a quarterly basis due to no consumers being in the facility as a result of the COVID 19 pandemic. Effective 2/28/2022, the Facility Director will ensure that fire drills are completed on a monthly basis and documented accordingly regardless of consumer presence in the facility. Building and agency management have been made aware of the necessity for this procedure. |
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
Based on a review of fire drill records between January 2020 and December 2021, the facility failed to maintain a written fire drill record documenting 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.
The following fire drill records did not include this documentation: February 2020, September 2020, November 2020, January - February 2021, May 2021, September 2021 and December 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 2/28/2022, the Facility Director will ensure that the approved Fire Drill form, which is in compliance and includes the dates, 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, is completed on a monthly basis for all fire drills conducted at the facility. Building and agency management have been made aware of the necessity for this procedure. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records between January 2020 and December 2021, the facility failed to document which alternate routes were used during fire drills. This information was missing on all drills documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 2/28/2022, the Facility Director will ensure that the approved Fire Drill form, which includes documentation of the alternate routes used during fire drills, is completed on a monthly basis for all fire drills conducted at the facility. |
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 a review of client records and an interview with the project/facility director, the facility failed to document a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in six of seven client records.
The facility billed for treatment services during the intake process without written consent from the client in the following records:
Client # 1 was admitted November 30, 2021.
Client # 2 was admitted August 16, 2021 and discharged January 5, 2022.
Client # 4 was admitted January 19, 2021 and discharged May 12, 2021.
Client # 5 was admitted March 8, 2021 and discharged April 19, 2021.
Client # 6 was admitted February 9, 2021 and discharged September 7, 2021.
Client # 7 was admitted June 3, 2020 and discharged October 7, 2021.
The findings were reviewed with staff during the licensing process.
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Plan of Correction
Beginning 2/28/2022, the Facility Director will be responsible for reviewing consents for all new clients and ensuring that all signatures are appropriately signed and dated. In addition to this, any request for release of information must be discussed between the treating clinician and the Facility Director, who will ensure that there is an appropriately signed and dated consent for the release of the requested information. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client that included the dated signature of the client in seven of seven client records.
Consents were documented during the intake process in the following client records.
Client # 1 was admitted November 30, 2021. Consents for insurance, emergency contact and pharmacy did not include the dated signature of the client.
Client # 2 was admitted August 16, 2021 and discharged January 5, 2022. Consents for insurance, emergency contact and a physician did not include the dated signature of the client.
Client # 3 was admitted September 2, 2021. Consents for insurance and an emergency contact included the client ' s signature but it was not dated.
Client # 4 was admitted January 19, 2021 and discharged May 12, 2021. Consents for insurance, emergency contact, a treatment provider and pharmacy did not include the dated signature of the client.
Client # 5 was admitted March 8, 2021 and discharged April 19, 2021. Consents for insurance and an emergency contact did not include the dated signature of the client.
Client # 6 was admitted February 9, 2021 and discharged September 7, 2021. Consents for insurance, emergency contact and a treatment provider did not include the dated signature of the client.
Client # 7 was admitted June 3, 2020 and discharged October 7, 2021. Consents for insurance, emergency contact and a government agency did not include the dated signature of the client.
The findings were reviewed with staff during the licensing process.
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Plan of Correction
Beginning 2/28/2022, the Facility Director will be responsible for reviewing consents for all new clients and ensuring that all signatures are appropriately signed and dated. In addition to this, any request for release of information must be discussed between the treating clinician and the Facility Director, who will ensure that there is an appropriately signed and dated consent for the release of the requested information. |
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.
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Observations
Based on a review of unusual incident reports and an interview with the project/facility director, the facility failed to document the Department was notified within three business days of the death of a client.
The project/facility director provided unusual incidents pertaining to the death of a client on the following dates: February 11, 2021, March 23, 2021, May 7, 2021 and August 16, 2021. There was no documentation the Department was notified of these incidents within three business days.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 2/28/2022, the Facility Director will ensure that all unusual incidents are reported to DDAP within three business days of the incident occurrence vis DDAP's Event Reporting System, in addition to agency reporting requirements, The Facility Director will complete an investigation of all reported incidents and will maintain a copy of the unusual incident reporting form in the facility file. |
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.
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Observations
Based on a review of client records, the facility failed to document the review and update of treatment and rehabilitation plans at least every 60 days in four of six client records.
Client # 2 was admitted August 16, 2021 and discharged January 5, 2022. The individual treatment plan was completed August 20, 2021. No treatment plan updates were documented.
Client # 3 was admitted September 2, 2021. The individual treatment plan was completed September 20, 2021. The only treatment plan update was documented on November 30, 2021.
Client # 4 was admitted January 19, 2021 and discharged May 12, 2021. The individual treatment plan was completed January 19, 2021. The only treatment plan update was documented on May 12, 2021.
Client # 6 was admitted February 9, 2021 and discharged September 7, 2021. The individual treatment plan was completed February 9, 2021. The only treatment plan updates were documented on April 17 and September 7, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 2/28/2022, Facility Director will review during supervisions consumers who have treatment plans expiring in the next 14 days. Staff will be responsible for ensuring that treatment plan reviews are completed in a timely manner. In the event that a consumer does not show for a scheduled appointment to complete a Treatment Plan review, a review of treatment progress will be documented in the electronic record by the primary therapist to ensure compliance within the (60) day time frame. On an ongoing basis to ensure that further deficiencies do not occur, the Facility Director will be responsible to review treatment plan expiration dates and provide necessary prompts and assistance to ensure timely completion of all treatment plan reviews. |
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.
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Observations
Based on a review of client records, the facility failed to document a complete client record including case consultation notes, per facility policy, in two of five client records.
The facility ' s policy requires a case consultation to be completed quarterly in the first year of treatment and annually thereafter.
Client # 2 was admitted August 16, 2021 and discharged January 5, 2022. No case consultation notes were documented.
Client # 7 was admitted June 3, 2020 and discharged October 7, 2021. The only case consultations were documented on August 16, 2020 and April 12, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 2/28/2022, a schedule to ensure that Case Consultations occur as required will be implemented by the Facility Director. All staff are responsible to review the schedule to ensure Case Consultations occur as scheduled. In addition, all staff are responsible for adding new consumers assigned to their caseloads to the schedule to include consumer initials, assigned clinician, MRN, date of needs assessment, date of 1st consult within 3 months, date of 6 month consult, date of 9 month consult, date of yearly consult and then ensuring yearly case consultation is scheduled thereafter and documented on the schedule accordingly. During weekly supervisions, the Facility Director will review the schedule with clinicians to provide necessary prompts and assistance to ensure timely completion of Case Consultations. |