INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 13, 2018 through November 14, 2018 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
The facility failed to ensure that there was documentation that employee #8, a counselor hired on September 1, 2008, received the required TB/STD communicable disease training within the regulatory timeframe, based on a review of the facility's Staffing Requirement Facility Report and the employee's personnel file.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #8 is scheduled to attend the TB/STD communicable disease training at Belmont Behavioral Hospital on 12/18/18. Going forward, HR will submit a quarterly report to the Project Director to ensure that new staff maintain 100% compliance with DDAP required training timeframes. |
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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in 7 of 14 client records reviewed.
Client #8 was admitted into the inpatient detox level of care on November 3, 2018 and was active at the time of inspection. There was documentation that contact was made to a funding source; however, there was no consent to release information documented in the record prior to the disclosures.
Client #9 was admitted into the inpatient detox level of care on October 24, 2018 and was active at the time of inspection. There was documentation that contact was made to a funding source; however, there was no consent to release information documented in the record prior to the disclosures.
Client #10 was admitted into the inpatient detox level of care on November 1, 2018 and was active at the time of inspection. There was documentation that contact was made to a funding source; however, there was no consent to release information documented in the record prior to the disclosures.
Client #11 was admitted into the inpatient detox level of care on February 10, 2018 and was discharged March 6, 2018. There was documentation that contact was made to a funding source; however, there was no consent to release information documented in the record prior to the disclosures.
Client #12 was admitted into the inpatient detox level of care on July 3, 2018 and was discharged July 17, 2018. There was documentation that contact was made to a funding source; however, there was no consent to release information documented in the record prior to the disclosures.
Client #13 was admitted into the inpatient detox level of care on February 22, 2018 and was discharged March 13, 2018. There was documentation that contact was made to a funding source; however, there was no consent to release information documented in the record prior to the disclosures.
Client #14 was admitted into the inpatient detox level of care on February 26, 2018 and was discharged March 9, 2018. There was documentation that contact was made to a funding source; however, there was no consent to release information documented in the record prior to the disclosures.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
For patients who present for inpatient detox level of care, a signed Release of Information (ROI) form for payers will be obtained at intake. If an individual refuses to sign the ROI to the payer, this will be noted on the form and staff will sign as a witness.
To monitor compliance, the Director of Admissions, or designee, will audit 100% of charts admitted to 3C (co-occurring unit). Audits will continue until 100% compliance is achieved for 4 consecutive months. |