INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 21, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mercy Behavioral Health 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 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential 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 observation during a physical plant inspection, the facility failed to maintain a well-secured railing for the outside steps located on the side of the building near the emergency exit.
The findings include:
A physical plant inspection was conducted on August 21, 2014 at approximately 12:45 PM. The facility has an emergency exit that leads to a set of outside steps located on the South 9th Street side of the building. The metal handrail for these steps is loose and the railing bolts are no longer secured to the concrete steps. The facility failed to maintain a well-secured railing for these outside steps.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/10/14, The general contractor for the Ownership Group of the building confirmed that work on this project will begin between 9/17/14 and 9/23/14 and will be completed within 30 days of commencement of work weather permitting.
Facilly Director and Supervisory team (Clinical Supervisor)of the project at this facility will monitor progress of the repairs needed to ensure the safety of those at this site.
Anticipated completion within 30 days of the start of the repairs.
Maintenance Supervisor of the facility will inspect railings monthly to ensure that they are secure and safe. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in two of two personnel records reviewed.
The findings include:
Seven personnel records were reviewed on August 21, 2014. Two personnel records pertained to new staff and were required to include documentation of fire extinguisher training upon staff employment. The facility failed to instruct employees # 3 and 4 in the use of the fire extinguisher upon their employment.
Employee # 3 was hired on May 1, 2014. Fire extinguisher training was not documented for employee # 3 until August 18, 2014. The facility failed to document fire extinguisher training upon staff employment.
Employee # 4 was hired on January 2, 2014. Fire extinguisher training was not documented for employee # 4 until August 18, 2014. The facility failed to document fire extinguisher training upon staff employment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Unit Manager of this facility will conduct this training within the first 7 days of working on the Unit. This will be evidenced by the staff signature and date on the Fire Safety Form which will include the proper use of a Fire Extinguisher. The form shall be kept on the Unit and filed in the employees personnel record. This will begin on 9/1/14 and will be ongoing. |
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 the facility's fire drill records, the facility failed to maintain a written fire drill record that included the exit route used and the amount of time it took for evacuation.
The findings include:
The facility's fire drill records from October 2013 through July 2014 were reviewed on August 21, 2014. The facility failed to maintain a written fire drill record including the exit route used for the following fire drills: 10/28/13, 12/21/13, 1/20/14, 2/19/14, 3/25/14 and 5/6/14. The facility failed to maintain a written fire drill record including the amount of time it took for the evacuation for the following fire drills: 2/19/14 and 3/25/14.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regulation was reviewed with staff who conduct fire drills at this facility on 8/22/14. They were instructed on proper completion of the fire drill logs. The log must be completed for each drill, and must indicate for each drill conducted, the exit that was used, the exit that was blocked, and the total time it takes for the evacuation. Unit Manager will review quarterly. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consent forms for the disclosure of information contained in the client record in ten of ten client records.
The findings include:
Ten client records were reviewed on August 21, 2014 for informed and voluntary consent to release client information forms. The facility failed to obtain informed and voluntary consent to release information forms in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
The facility's consent to release client information form is a standardized form with a revision date of May 2012. The consent form included the following statement: "I understand that I may revoke this authorization at any time. My revocation must be in writing". 42 CFR Part 2, Subpart C, subsection 2.31 (a) Required elements, specifies that the following information must be included on the written consent: "(8) A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it." Therefore, as per 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) the consent to release client information form can be revoked by the client at any time and there is no restriction on the manner in which they may revoke it. The facility failed to adhere to the requirements outlined in the federal confidentiality regulations by requiring the clients to revoke consent forms in writing.
The facility director confirmed that the facility's consent to release information forms contained in the client records included the statement that required the client to revoke the consent in writing.
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Plan of Correction
Consent to release form will be changed to include language that includes the revocation of a consent can be completed verbally for alcohol and other drug project participants.
Project Policy and Proecedures will be reviewed to ensure compliance with42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8).
Faciliy Director will ensure that consent to release and Policy and Procedures will be updated and changed as indicated above. Changes to the consent to release form will be reviewed with all project staff in a staff meeting by Clinical Supervisors.
All form changes, trainings, and implementation will occur by November 14, 2014.
Faciliy Director and Clinical Supervisors will montior records for full compliance with the changes. |