INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on August 14, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Behavioral Wellness Center at Girard Goldman Clinic 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 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's October 2023 through June 2024 fire drill logs, the facility failed to ensure that unannounced fire drills were conducted at least once a month.
There were no fire drills documented, in the fire drill log, during the months of March 2024 and May 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Security at The Behavioral Wellness Center will ensure monthly fire drills are conducted during hours of operation.
Quarterly the VP of Operations will monitor the fire log to ensure that drills are occurring monthly during the hours of operation. |
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 October 2023 through June 2024 fire drill logs, the facility failed to include on their written fire drill log which exit route was used during the drills. The November 2023 and December 2023 fire drill logs were missing the exit route used during the conducted drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Security will document on the fire drill log the exit used during evacuation. This will occur with each monthly fire drill.
The VP of Operations will review the logs quarterly to ensure that the evacuation exit is identified on each monthly log. |
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
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 1 was admitted on October 23, 2008 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On admission, the admissions coordinator will provide the participant with informed consents of release of information identifying the source the information is released to prior to disclosure.
The ROI will be updated and corrected for client #1 by September 25th.
BWC supervisor/director will monitor charts quarterly, a total of 6 admission charts over the next three months to ensure compliance. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure copies of client consent to release information forms were offered to the client in one of seven client records reviewed.
Client # 3 was admitted on June 10, 2024 and was still active at the time of the inspection. The release of information forms to an emergency contact, a funding source, a government agency, and a transportation company were signed by the client on June 10, 2024; however, there was no documentation that a copy of any of the consent forms were offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisors/Director will provide supervision on consents requirements per DDAP regulations, ensuring that all clients are offered a copy of the consents.
To address this deficiency, Client #3 will be offered a copy of the consent forms and the indicator that the forms were offered will be marked.
Supervisors will focus monitor 6 random charts per month for 60 days for all consent requirements per DDAP and BWC policy.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of one applicable patient records reviewed.
Patient # 2 was transferred in and admitted on June 18, 2024 and was still active at the time of inspection. There was no documentation in the record that the transferring narcotic treatment program was notified of the client ' s date of admission and the date the initial dose was given.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Admission coordinator/assigned staff will ensure that transfer documentation is provided to external providers. A copy will be scanned into the client's EMR chart to include the last dose verification and FAX or email confirmation.
Admission coordinator or assigned staff will provide the former clinic of transferring admitting client dose and admission verification. A copy of the FAX or email will be uploaded to the clients EMR.
Director of the BIU will audit charts monthly to ensure notification has been provided and uploaded to the client's EMR. |