INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 28, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Safe Harbor Behavioral Health of UPMC Hamot 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
The facility failed to maintain a written fire drill log that included, 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, in fire drill logs reviewed on February 28, 2017. Fire drill logs were reviewed for the time period of July 2016 to January 2017. All were missing the above information. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Review policy and procedure on fire drills for a non-residential facility 705.28 (d)
a. AMS staff will revise current written fire drill documentation to include date, item, the amount of time it took for evacuation, exit route used, number of person in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative. By 3/23/17. Responsible Parties: Project Director, Clinical Supervisor, Manager of Information Systems, Safety Officer
b. AMS staff will conduct fire drills on different days of the week, at different times of the day and on different staffing shifts. Schedule created by 3/23/17. Responsible Parties: Project Director, Clinical Supervisor, Manager of Information Systems, Safety Officer
c. AMS will identify changes made to fire drill document and review process with Safety committee on 3/23/17.Responsible Parties: Project Director, Clinical Supervisor, Manager of Information Systems, Safety Officer
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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
The facility failed to obtain an informed and voluntary consent from the client in seven of seven records reviewed on February 28, 2017. Seven records were reviewed. Client record #1 was missing a consent to release information for the funder. In client records # 2, 3, 4, 5, 6 and 7, the consent to release stated that the release could only be revoked in writing. These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Replace current PCP ROI in financial intake with ROI that meets 255.5 criteria, by 3/17/17. Responsible: Project Director, Clinical Supervisor, Administrative Assistant, Financial Intake, Business Manager, Privacy Officer
2. Supervisor will educate staff on PCP ROI during staff meeting on 3/3/17. Responsible: Clinical Supervisor.
3. Staff will begin to obtain PCP ROI on current and existing clients to ensure charts are in compliance as of 3/17/17. Responsible: Clinical Supervisor, Administrative Assistant, Business Manager, Financial Intake Supervisor
4.
1. Will insert insurance ROI into the financial forms group during initial intake process by 3/17/17. Responsible: Clinical Supervisor, Administrative Assistant, Business Manager, Financial Intake Supervisor
2. Supervisor will educate staff on insurance ROI during staff meeting on 3/3/17. Responsible: Clinical Supervisor
3. Staff will begin to obtain insurance ROI on current and existing clients to ensure charts are in compliance as of 3/17/17. Responsible: Project Director, Clinical Supervisor, Administrative Assistant, Business Manager, Financial Intake Supervisor
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