INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 9, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Brookdale 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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705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection, the facility failed to maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail. Stairs exiting the kitchen had five steps without a handrail.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facilities Director ordered the handrail and brackets on June 8, 2023, for the five stairs exiting the kitchen. The Facilities Director will be responsible for maintaining ongoing compliance with a yearly inspection of the physical plant to include all stairways. The Facilities Director will ensure a well-secured handrail will be in place for the stairs exiting the kitchen and will be in full compliance with the standard by June 13,2023. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility grievance policy and client records, the facility failed to follow the grievance policy in client record # 7. The facility policy and procedure manual states " Any person(s) who believes that their rights have been violated or has a compliant or grievance may file a complaint pursuant to the procedures set forth below...". By filing a complaint, the individual will not subject themselves to any form of adverse action, reprimand, retaliation, or otherwise negative treatment by Brookdale 5723.1. Patients are encouraged to discuss any problems with their therapist to try to find a resolution...2. All grievances shall be first be filed with your primary therapist by completing a "Patient Grievance" form. The director of the department shall conduct an internal investigation and render an initial determination and resolution within 5 days of receipt of the complaint in writing.3. If complainant is not satisfied or if the complainant is not resolved with the results achieved in step 2, the complainant may file an appeal and/or the grievance shall be forwarded to the director of operations and meeting held within 5 business days.4. If the patient and director of operations are unable to resolve the grievance, it shall be referred to the executive director who shall have five working days to make a final determination on the appeal. the executive director will review all available documentation and prior determination in an effort to ascertain the facts and events relative to the grievance.5. The patient shall meet with the executive director and be presented a resolution and response to their grievance in writing.Client # 7 was admitted on September 2, 2022 and was administratively discharged on September 7, 2022. Client # 7 requested to file a grievance in response to the client being administratively discharged. The client was told "this is an internal procedure and to follow up with the CEO after he leaves". Client # 7 was not able to file a grievance.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Compliance officer conducted Grievance Training for the clinical treatment team on June 6,2023. Staff were provided with the Grievance policy and procedure and signed a Departmental In-service form for the training. Grievance Training will be provided to all staff upon hire and ongoing yearly training will be provided by the Chief Compliance officer for clinical staff. On June 6,2023 Brookdale is in full compliance with the standard. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on two of two applicable client record reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate and the opportunity to request reconsideration of a decision terminating treatment the client's treatment in client record # 7 and # 14.Client # 7 was admitted on September 2, 2022 and was administratively discharged on September 7, 2022. There was no documentation in the client record notifying the client in writing of termination from the project.Client # 14 was admitted on September 25, 2022 and was administratively discharged on September 29, 2022. There was no documentation in the client record notifying the client in writing of termination from the project.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On May 9,2023 the Chief Compliance Officer enabled the Involuntary Notification to terminate treatment form in the electronic medical record. The facility will provide documentation to the patient notifying them, in writing, of a decision to involuntarily terminate treatment and the opportunity to request reconsideration of the decision to terminate their treatment. The compliance department will be responsible for ongoing compliance by auditing patient charts weekly for involuntary terminations and the Involuntary Notification treatment forms. On May 9, 2023, Brookdale is in full compliance with the standard. |