INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 15, 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 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) (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 was no documentation, in the fire drill logs, that a fire drill was conducted during the month of March 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. |
709.30 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.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by the client that they had been notified of their regulatory client rights in three of seven client records reviewed.
Client #4 was admitted to the intake, evaluation and referral activity on April 12, 2024 and was discharged April 12, 2024. There was no written acknowledgment documentation, in the record, indicating the client was notified of their client rights.
Client #6 was admitted to the intake, evaluation and referral activity on May 21, 2024 and was discharged May 21, 2024. There was no written acknowledgment documentation, in the record, indicating the client was notified of their client rights.
Client #7 was admitted to the intake, evaluation and referral activity on June 3, 2024 and was discharged June 3, 2024. There was no written acknowledgment documentation, in the record, indicating the client was notified of their client rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Admissions Director will ensure that clients receive written acknowledgment of client's rights. The admissions coordinator will be responsible to provide a copy of the client's rights and have the clients sign the acknowledgement and receipt of their rights.
The seven client that were not provided with a copy of their rights will be provided a copy of client rights and acknowledgment will be signed by 10/15/2024
The Admissions Director will audit charts monthly to ensure compliance. |
709.44(a)(2) LICENSURE Consent Forms
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(2) Consent forms.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of consent forms, in three of seven client records reviewed.
Client #4 was admitted to the intake, evaluation and referral activity on April 12, 2024 and was discharged April 12, 2024. There was no documentation of consent forms in the record prior to discharge.
Client #6 was admitted to the intake, evaluation and referral activity on May 21, 2024 and was discharged May 21, 2024. There was no documentation of consent forms in the record prior to discharge.
Client #7 was admitted to the intake, evaluation and referral activity on June 3, 2024 and was discharged June 3, 2024. There was no documentation of consent forms in the record prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Admissions Director/Supervisor will provide supervision on consent requirements per DDAP regulations, ensuring that all clients are offered a copy of the consents. To address this deficiency clients #4,6 and 7 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. |