INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 13, 2022 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 IOP-CAP 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) (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 2021 through August 2022 fire drill logs, the facility failed to ensure that their written fire drill log included 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, and whether the fire alarm or smoke detector was operative.
The November 2021, December 2021, March 2022, June 2022 and August 2022 fire drill logs were missing the amount of time it took for evacuation. Also, the December 2021, March 2022, June 2022 and August 2022 fire drill logs were missing the exit route used. Additionally, the February 2022 fire drill log was missing number of persons in the facility at the time of the drill and the December 2021 fire drill log was missing whether the fire alarm or smoke detector was operative.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Security/Fire Marshal will review and update all current logs and fire drill forms as permitted. The Director will update all individual fire drill forms to include 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. The Director will develop a comprehensive log which consolidates all the drills and includes all of the required information. |
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 # 4 was admitted on December 7, 2021 and was still discharged on April 13, 2022. There was evidence of a disclosure to a government agency on December 22, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will provide an in-service by October 6, 2022 for all clinicians on the proper way of completing consent to release information and ensuring that consents to release information are obtained prior to disclosure. In addition, Clinical supervisor will monthly chart audits to ensure that consents are completed properly. |
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made on consent to release information forms in three of seven of client records reviewed.
Client # 2 was admitted March 16, 2022 and was still active at the time of the inspection. The release of information form to the "probation and parole department" was signed and dated by the client on March 16, 2022; however, the form failed to document the specific name of the person, agency, or organization to whom the disclosure would be made.
Client # 4 was admitted December 7, 2021 and was discharged on April 13, 2022. The release of information form to the "probation and parole department" was signed and dated by the client on December 7, 2021; however, the form failed to document the specific name of the person, agency, or organization to whom the disclosure would be made.
Client # 5 was admitted January 31, 2022 and was discharged on July 6, 2022. A blank release of information form and a release of information form to the "probation and parole department" were signed and dated by the client on January 31, 2022; however, both forms failed to document the specific name of the person, agency, or organization to whom the disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will provide an in-service by October 6, 2022 for all clinicians on the proper way of completing consent to release information and ensuring that consents indicate the name of the person, organization, and or agency to whom the disclosure is made. In addition, Clinical supervisor will monthly chart audits to ensure that consents are completed properly.
ROI for all active clients will be reviewed and corrected by counselor by October 14, 2022. |
709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review client records, the facility failed to document the purpose of the disclosure on release of information forms in two of seven client records reviewed.
Client # 2 was admitted March 16, 2022 and was still active at the time of the inspection. The release of information form to the probation and parole department was signed and dated by the client on March 16, 2022, but the form did not include the purpose of the disclosure.
Client # 5 was admitted January 31, 2022 and was discharged on July 6, 2022. The release of information form to the probation and parole department was signed and dated by the client on January 31, 2021, but the form did not include the purpose of the disclosure.
This is a repeat citation from the September 29, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will provide an in-service by October 6, 2022 for all clinicians on the proper way of completing consent to release information and ensuring that consents to release information indicate the purpose of the disclosure of the release of information. In addition, Clinical supervisor will monthly chart audits to ensure that consents are completed properly.
ROI for all active clients will be reviewed and corrected by counselor by October 14, 2022. |