INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 17, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Belmont Behavioral Hospital, LLC 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in one of one applicable personnel record reviewed.
Employee #7 was hired as a counselor on August 29, 2022. HIV/AIDS training was due to be completed no later than August 29, 2023; however, it was completed on September 16, 2023. TB/STD training was due to be completed no later than August 29, 2023; however, it was completed on October 2, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Office/Project Director will schedule and facilitate quarterly meetings with key clinical leaders to review the status of training plans and requirements. Clinical leaders will be responsible for ensuring training for their staff occurs timely. Evidence of trainings will be submitted to the Project Director as they are completed rather than annually. |
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 ensure that a copy of consent to release information forms were offered to the client in five of seven client records reviewed.
Client #1 was admitted on October 6, 2023 and was active at the time of inspection. Release of information forms to the primary care physician, emergency contact, and funding source were signed and dated by the client on October 6, 2023; however, there was no documentation that copies of the forms were offered to the client.
Client #2 was admitted on October 11, 2023 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on October 16, 2023; however, there was no documentation that a copy of the form was offered to the client.
Client #3 was admitted on October 4, 2023 and was active at the time of inspection. Release of information forms to the emergency contact and funding source were signed and dated by the client on October 4, 2023; however, there was no documentation that copies of the forms were offered to the client.
Client #4 was admitted on July 29, 2023 and was discharged on August 14, 2023. Release of information forms to the primary care physician, emergency contact, and funding source were signed and dated by the client on July 29, 2023; however, there was no documentation that copies of the forms were offered to the client.
Client #5 was admitted on July 2, 2023 and was discharged on July 28, 2023. A release of information form to an external treatment provider was signed and dated by the client on July 25, 2023; however, there was no documentation that a copy of the form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Release of Information will be revised to include a section to reflect evidence that the client was offered a copy of the consent.
Education will be completed with Intake and Social Services/Case Management staff about the requirement to offer a copy of the consent to the client and how to document it.
Audit 30 records per month until 100% compliance is achieved for 3 consecutive months.
Clients 1-3 were discharged prior to the form change. Clients 4-5 had already been discharged prior to the inspection.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgment by the client that the client had been informed of their right to inspect their own records in five of seven client records reviewed.
Client #1 was admitted on October 6, 2023 and was active at the time of inspection.
Client #2 was admitted on October 11, 2023 and was active at the time of inspection.
Client #3 was admitted on October 4, 2023 and was active at the time of inspection.
Client #4 was admitted on July 29, 2023 and was discharged on August 14, 2023.
Client #5 was admitted on July 2, 2023 and was discharged on July 28, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Bill of Rights will be amended to include the following language: Clients have the right to inspect their own records.
The amended Bill of Rights will be reflected in the EMR, downtime forms, postings, and within the Belmont PRS/Family Handbook.
Clients 1-3 were discharged prior to the form change.
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgment by the client that the client had been informed of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in five of seven client records reviewed.
Client #1 was admitted on October 6, 2023 and was active at the time of inspection.
Client #2 was admitted on October 11, 2023 and was active at the time of inspection.
Client #3 was admitted on October 4, 2023 and was active at the time of inspection.
Client #4 was admitted on July 29, 2023 and was discharged on August 14, 2023.
Client #5 was admitted on July 2, 2023 and was discharged on July 28, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Bill of Rights will be amended to include the following language: Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
The amended Bill of Rights will be reflected in the EMR, downtime forms, postings, and within the Belmont PRS/Family Handbook.
Clients 1-3 were discharged prior to the form change.
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709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgment by the client that the client had been informed of their right to submit rebuttal data or memoranda to their own records in five of seven client records reviewed.
Client #1 was admitted on October 6, 2023 and was active at the time of inspection.
Client #2 was admitted on October 11, 2023 and was active at the time of inspection.
Client #3 was admitted on October 4, 2023 and was active at the time of inspection.
Client #4 was admitted on July 29, 2023 and was discharged on August 14, 2023.
Client #5 was admitted on July 2, 2023 and was discharged on July 28, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Bill of Rights will be amended to include the following language: Clients have the right to submit rebuttal data or memoranda to their own records.
The amended Bill of Rights will be reflected in the EMR, downtime forms, postings, and within the Belmont PRS/Family Handbook.
Clients 1-3 were discharged prior to the form change.
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709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of a physical assault or sexual assault by staff or a client.
A physical assault by a client occurred on June 10, 2023 and it was not reported to the Department within 3 business days. The incident was reported on October 17, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Risk Director will review with Risk Managers Incident Reporting requirements outlined in 709.34. Once weekly, the Risk Director or delegate will review all reported incidents and compare to DDAP Incident Reporting portal to ensure reports were filed for all incidents meeting criteria. |