INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 1, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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:
|
Plan of Correction
|
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
The facility failed to ensure that unannounced fire drills were conducted at least one time a month. Based on a review of the January 2020 through November 2020 fire drill logs, there was no documentation that the facility conducted a fire drill in March 2020.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Plant Operations will ensure a fire drill occurs each month. Suspension of drills must be authorized by the Project Director only when an exemption has been authorized by DDAP.
|
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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.
|
Observations
The facility failed to ensure that a complete written fire drill record was maintained. Based on a review of the January 2020 through November 2020 fire drill logs, the January 2020, February 2020, April 2020, June 2020 and July 2020 fire drill logs were missing the exit route used and the number of persons in the facility at the time of the drill. Additionally, the May 2020, August 2020, September 2020, October 2020 and November 2020 fire drill logs were missing the amount of time it took for evacuation, the exit route used and the number of persons in the facility at the time of the drill.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Plant Operations will amend the Fire Drill Report form to include prompts for exit route and number of persons in the facility at the time of the drill. The Director of Plant Operations will complete education with all fire drill operators to review the revised form and reinforce requirements. The Director of Plant Operations will review each Fire Drill Report form following the event for completion.
|
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
The facility failed to ensure that a fire drill during sleeping hours was conducted at least one time every six months. Based on a review of the January 2020 through November 2020, there was no documentation that a fire drill was conducted during sleeping hours.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director will provide the Plant Operations Director with the programming schedule that indicates sleeping hours. The Director of Plant Operations will be responsible for ensuring at least one drill occurs every six months during sleeping hours.
|
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.
|
Observations
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in two of seven patient records reviewed.
Patient #4 was admitted on October 6, 2020 and was discharged on October 20, 2020. There was evidence of disclosures to the funding source during the patient's treatment episode; however, there was no consent to release information form signed by the patient documented in the record prior to the disclosures.
Patient #5 was admitted on July 22, 2020 and was discharged on August 3, 2020. There was evidence of disclosures to the funding source during the patient's treatment episode; however, there was no consent to release information form signed by the patient documented in the record prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Social Services and the Director of Admissions will conduct trainings with their respective staff members on obtaining informed and voluntary consent for disclosure of information to funding sources. The Clinical Supervisor or designee will conduct monthly audits (25) of Funding Consents until compliance is sustained for three months above 90%. The outcome of monthly audits will be monitored through Quality Council. The Director of Social Services and the Director of Admissions or their designees are responsible for any necessary follow-up actions.
|
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
The facility failed to document, in writing, that the patients were informed that all patients receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain all civil rights and liberties except as provided by statute and that no patient may be deprived of a civil right solely by reason of treatment in seven of seven patient records reviewed.
Patient #1 was admitted on November 5, 2020 and was still active at the time of the inspection.
Patient #2 was admitted on November 19, 2020 and was still active at the time of the inspection.
Patient #3 was admitted on November 12, 2020 and was still active at the time of the inspection.
Patient #4 was admitted on October 6, 2020 and was discharged on October 20, 2020.
Patient #5 was admitted on July 22, 2020 and was discharged on August 3, 2020.
Patient #6 was admitted on January 14, 2020 and was discharged on January 27, 2020.
Patient #7 was admitted on December 22, 2019 and was discharged on January 2, 2020.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Quality will be responsible for modifying the PRS Rights form to specifically include the right to retain civil liberties as provided by statute. The Director of Quality will work with the Director of HIM to ensure the modified form replaces the previous version.
To ensure patients have been informed of their rights, patients 2 and 3 were provided with an updated PRS Rights form on 12/31/20. Patient 1 was discharged on 12/4/2020. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
|
Observations
The facility failed to document, in writing, that the patients were informed that all patients have the right to appeal a decision limiting access to their records to the director in seven of seven patient records reviewed.
Patient #1 was admitted on November 5, 2020 and was still active at the time of the inspection.
Patient #2 was admitted on November 19, 2020 and was still active at the time of the inspection.
Patient #3 was admitted on November 12, 2020 and was still active at the time of the inspection.
Patient #4 was admitted on October 6, 2020 and was discharged on October 20, 2020.
Patient #5 was admitted on July 22, 2020 and was discharged on August 3, 2020.
Patient #6 was admitted on January 14, 2020 and was discharged on January 27, 2020.
Patient #7 was admitted on December 22, 2019 and was discharged on January 2, 2020.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Quality will be responsible for modifying the PRS Rights form to specifically include language regarding the right to appeal a decision limiting access to their records to the director. The Director of Quality will work with the Director of HIM to ensure the modified form replaces the previous version.
To ensure patients have been informed of their rights, patients 2 and 3 were provided with an updated PRS Rights form on 12/31/20. Patient 1 was discharged on 12/4/2020. |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
|
Observations
The facility failed to file a written unusual incident report with the Department within 3 business days following an incident involving a physical assault by staff or a patient. Based on the review of the facility's unusual incident log, physical assault incidents that occurred on July 23, 2020 and November 1, 2020 were not reported to the Department as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director will review unusual incident reporting requirements with the Risk Manager and Risk Director to include categories of reportable incidents and the mechanism for reporting. Incident reports for physical assaults that occurred on 7/23/20 and 11/1/2020 will be be submitted by the Risk Director or Risk Manager. The Risk Director is responsible for ensuring compliance with reporting requirements.
|
709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
The facility failed to file a written unusual incident report with the Department within 3 business days following an incident requiring the presence of ambulance personnel at the facility. Based on the review of the facility's unusual incident log, ambulance personnel were needed onsite on the following dates and none of the incidents were reported to the Department as of the date of the inspection:
January 7, 2020
January 8, 2020
February 23, 2020
April 1, 2020
April 9, 2020
May 26, 2020
May 30, 2020
June 19, 2020
July 10, 2020
August 18, 2020
August 25, 2020
August 29, 2020
September 26, 2020
October 20, 2020
November 10, 2020
November 25, 2020
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director will review unusual incident reporting requirements with the Risk Manager and Risk Director to include categories of reportable incidents and the mechanism for reporting. Incident reports for medical events that occurred on 1/7, 1/8, 2/23, 4/1, 4/9, 5/26, 5/30, 6/19, 7/10, 8/18, 8/25, 8/29, 9/26, 10/20, 11/10, & 11/25 will be be submitted by the Risk Director or Risk Manager. The Risk Director is responsible for ensuring compliance with reporting requirements.
|