INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 4, 2017 through December 6, 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, 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 facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #6 received the 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.
Employee #6 was hired as the project director on 01/05/15 and was due to have the communicable disease trainings no later than 01/05/17. There was no documentation in the personnel file of the completion of the required 6 hours of HIV/AIDS training and the required 4 hours of TB/STD training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #6 was hired on 1/5/15 as a Behavioral Health Associate (BHA) assigned to an adult general psychiatric unit. It was not until the 8/21/17 that employee #6 began working shifts on Belmont's co-occurring unit (3C). This places her within the required timeframe (2 years) for obtaining 6 hours of HIV/AIDS training and 4 hours of TB/STD training. Employee #6 resigned from Belmont on 12/26/17.
Going forward, in addition to having the option to attend department-approved external trainings, Belmont will offer internal HIV/AIDS and TB/STD training to staff.
Department managers will ensure that their respective staff working on 3C receive the department-required trainings within the designated timeframes.
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on the physical plant inspection conducted on 12/5/17, it was discovered that the facility failed to maintain client records in locked storage containers at all times as a client's record was found unattended and sitting on the nursing station desk.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A memo was sent to all staff on regulation §709.28. Confidentiality, reminding them that if they need to walk away from the nursing station while working on a record, they should return it to the locked chart room or place it in a locked drawer/storage area behind the nursing station.
The Privacy Officer will conduct a walk-through of the co-occurring unit (3C) once a month for 4 consecutive months with no findings to ensure that no confidential information is left unattended.
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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
After a review of the project's client rights policy, the project failed to include the following elements:
1) 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. The reasons for removing those sections must be documented in the record.
2) Clients have the right to appeal a decision limiting access to their records to the director.
3) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
4) Clients have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff.
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Plan of Correction
PRS Rights and Responsibilities Policy 360.12, Section IV, 16 was revised to include:
"'Health information' includes records pertaining to drug and alcohol treatment. According to PA Code 709.30 Client Rights:
1) 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. The reasons for removing those sections must be documented in the record.
2) Clients have the right to appeal a decision limiting access to their records to the director.
3) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
4) Clients have the right to submit rebuttal data or memoranda to their own records."
The revised policy was distributed to all staff via email.
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709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
After a review of the project's unusual incident policy, the project failed to develop, include, and implement the following as part of the project's policies:
(1)The implementation of a timely and appropriate corrective action plan, when indicated.
(2)A way to document the ongoing monitoring of the corrective action plan.
These findings were reviewed with facility staff.
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Plan of Correction
Incident Reporting Policy 150.01 was revised to include under section 5.2, "The Manager or Department Director will document preliminary incident review and implement timely and appropriate corrective action to be documented in the 'Actions Taken/Follow-Up Info/Recommendations as a result of the Incident' section on page #2 of the Incident Report, when indicated. The responsible manager will maintain documentation of the ongoing monitoring of the action plan, if required."
The revised policy was distributed to Belmont's leadership team with a reminder to maintain documentation of ongoing monitoring of incident action plans when required.
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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 14 client records, 5 client records had treatment plan updates that were completed after the regulatory timeframe.
Client #1 was admitted on 6/29/16 and was an active client at the time of inspection. A treatment plan update was completed on 2/9/1717 and the next update was due no later than 4/9/17. However, the update was not completed until 4/20/17.
Client #3 was admitted on 1/30/17 and was an active client at time of inspection. A treatment plan update was completed on 5/4/17 and the next update was due no later than 7/4/17. However, the update was not completed until 7/13/17.
Client #4 was admitted on 8/8/16 and was discharged on 8/29/17. A treatment plan update was completed on 11/9/16 and the next update was due no later than 1/9/17. However, the update was not completed until 1/31/17.
Client #5 was admitted on 10/24/17 and was discharged on 7/21/17. A treatment plan update was completed on 3/24/17 and the next update was due no later than 5/24/17. However, the update was not completed until 6/15/17.
Client #7 was admitted on 8/11/16 and was discharged on 8/25/17. A treatment plan update was completed on 9/14/16 and the next update was due no later than 11/14/16. However, that update was not completed until 2/3/17. Additionally, another treatment plan update was completed on 2/3/17 and the next update was due no later than 4/3/17. However, the update was not completed until 4/20/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director educated staff on 12/21/17 on regulation 709.92. Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
The Program Director will randomly select one chart from each therapist (6) biweekly to ensure compliance with timeliness of treatment plan updates. Compliance issues will be addressed with individual therapists as identified. The audit will continue until 90% compliance is achieved for 4 consecutive months.
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