INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 24, 2016 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, John F. Kennedy Behavioral Health Center 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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709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
On October 24, 2017, it was discovered that since the previous licensing inspection, the facility had one client death while they were an active client. The facility was notified of the death on December 30, 2016. Upon further inspection, it was discovered that the facility failed to submit a written unusual incident report informing the Department about the incident.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.34(c)(2)
when an unusual incident occurs such as death, a serious injury due to trauma,suicide, medication error, or other circumstances, the appropriate staff member will complete the unusual incident report and file with the Department within 3 business days of the incident. The supervisor will ensure the procedure is followed
Effective 12/1/2017 |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of seven client records, the facility failed to provide a complete client record in one of two applicable records requiring follow-up information.Client #7 was admitted on 11/11/15 and was discharged on 05/31/17. The client record did not contain any documentation of follow-up information 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
709.93(1) Client Records/ Follow up
Upon discharge of a client, a follow up phone call or letter will be sent by the counselor within thirty days of discharge inviting the client to re-engage in treatment services at JFK. The supervisor will be responsible to ensure that the standards have been met.
effective 12/1/2017 |