INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 12, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, UPMC Western Behavioral Health at Safe Harbor 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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705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on the physical plant inspection, the facility failed to provide a wall mirror in each bathroom. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the Physical Plant inspection, on 1/12/22 Program Manager ensured that the bathroom that was inspected on 1/12/22 had a mirror replaced in the identified bathroom. On 1/13/22 a photo was sent to DDAP licensing inspector showing that the mirror was replaced.
OP Nurse coordinator will begin monitoring each bathroom and maintaining a monthly log ensuring each bathroom has a mirror. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility fire drill records between April 2021 and December 2021, the facility failed to document which alternate routes were used during fire drills. All of the fire drills reviewed included both exit " A & B " were used.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager provided education to staff on 1/19/22 on using alternate routes used during a fire drill. Education was provided on properly filling out documentation for fire drills.
OP nurse coordinator will complete monthly fire drill logs indicating alternate routes have been utilize.
Program Manager will review and sign off on monthly fire drills to ensure alternate routes are used. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility fire drill records between April 2021 and December 2021, the facility failed to set off a fire alarm or smoke detector during each fire drill. This information was missing on the fire drills documented from April 2021 to November 2021.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/12/22 Project Director requested an exemption from DDAP "705.28(d)(7) Set off a fire alarm or smoke detector during each fire drill in a nonresidential facility" as the Outpatient facility is in a building that is co-Located with an Ob/GYN practice and setting off the fire alarm and smoke detectors would be disruptive to this practice.
OP Nurse Coordinator will maintain fire drill inspections and fire safety by completing all other fire drill elements as outlined in the regulations. Each month OP Nurse Coordinator will continue to complete unannounced fire drills, during normal staffing conditions, and a written record of each drill will be maintained.
The Ob/GYN Practice tests their alarm system one time per year and tests the batteries on the alarm lights monthly. A writer record of the Ob/GYN tests will be provided to DDAP.
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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 obtain an informed and voluntary consent from the client prior to disclosure in one of seven client records reviewed. Client #3 was admitted on July 28, 2021 and was discharged on October 5, 2021. Documentation via a fax form noted a referral was made to another human service agency on July 29, 2021, but a release of information was not signed. The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On 1/18/22 Program Manager reviewed specifics of the citation with staff and information that can be disclosed and the need to obtain a written release of information from a client prior to disclosure.
OP staff will obtain release of information prior to disclosure of client records.
This element will be incorporated into the Clinical Supervisor's monthly chart audits, which are part of the quality assurance committee's monthly reporting.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility exceeded the limitations imposed by 4 Pa. Code 255.5 when documenting the specific information disclosed to a government agency on the consent to release information form in one of seven client records.Client #1 was admitted on April 7, 2021 and was discharged on August 3, 2021. A release of information for a government agency was signed on April 26,2021. The specific information indicated on the form allows for disclosure of medications and treatment plans, which exceeds 255.5.The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On 1/18/22 Program Manager reviewed 255.5 requirements with staff on specifics information that can be disclosed to a government agency and provided staff with a copy of the confidentiality guidelines.
This element will be incorporated into the Clinical Supervisor's monthly chart audits, which are part of the quality assurance committee's monthly reporting and will address future clients. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document the review and update of treatment and rehabilitation plans at least every 60 days in five of seven client records.Client #2 was admitted on July 21, 2021 and was discharged on November 2, 2021. The individual treatment plan was completed on July 21, 2021. A treatment plan update was due to be completed on September 21, 2021 and was documented late on October 5, 2021.Client #3 was admitted on July 28, 2021 and was discharged on October 5, 2021. The individual treatment plan was completed on July 28, 2021. A treatment plan update was due to be completed on September 28, 2021 and was not documented.Client #4 was admitted on June 9, 2021 and was discharged on September 2, 2021. The individual treatment plan was completed on June 9, 2021. A treatment plan update was due to be completed on August 9, 2021 and was not documented. Client #5 was admitted on April 28, 2021 and was still a client at the time of the inspection. The individual treatment plan was completed on April 28, 2021. Treatment plan updates were completed on June 30, 2021, and August 31, 2021. A treatment plan update was due to be completed on October 31, 2021 and was documented late on November 16, 2021.Client #6 was admitted on September 21, 2021 and was still a client at the time of the inspection. The individual treatment plan was completed on September 21, 2021. A treatment plan update was due to be completed on November 21, 2021 and was documented late on December 28, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/18/2022 Program Manager reviewed requirements with outpatient staff to ensure reviews are completed at least every 60 days, even if the individual in services is not present.
As of February 2022, the Clinical Supervisor will monitor this charting element in monthly audits, which are then reported to the Quality Assurance Committee and will be reviewed for future clients.
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