INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 18, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Hope Springs Behavioral Health Inc. 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 fire drill log, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
The facility's fire drill log was reviewed on February 18, 2016 covering the period of March 2015 through February 2016. The facility failed to set off a fire alarm or smoke detector during the fire drills for the month of March 2015, April 2015, May 2015, June 2015, July 2015, August 2015, September 2015, October 2015, November 2015, December 2015, January 2016, and February 2016.
These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will fax over a letter of Request to DDAP on by 03/01/2016 for the Exception to set off fire alarm due to surrounding business disruption.
Facility Director or designated safety officer will set off a portable bell and continue with monthly, documented drills as required.
If Exception Request is not granted, facility will follow licensing guidelines.
Fire Inspection will be conducted annually as well as Fire Extinguisher; this will be the responsibility of the Facility Director. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to adhere to the requirements specified at 4 Pa. Code 255.5 (b) and 42 CFR relating to specific information disclosed.
The findings include:
On February 18, 2016, five client records were reviewed to ensure compliance with 4 Pa. Code 255.5. The facility failed to adhere to the requirements in four out of five client records, specifically client records #1, 2, 3, and 5.
Client #1 was admitted on April 13, 2015 and was still an active client at the time of inspection. A consent to release form for an insurance company was signed by the client on April 13, 2015. The release form allowed for the release of assessments and evaluations, entire mental health record, summary of treatment, psychosocial history, and discharge summary. This exceeds the limits imposed by 4 Pa. Code 255.5.
Client #2 was admitted on March 17, 2015 and was still an active client at the time of inspection. A consent to release form for an insurance company was signed by the client on March 17, 2015. The release form did not indicate specific information to be released by leaving assessment and evaluations blank.
Client #3 was admitted on January 19, 2016 and was still an active client at the time of inspection. A consent to release form for an insurance company was signed by the client on January 19, 2016. The release form allowed for the release of assessments and evaluations, entire mental health record, summary of treatment, psychosocial history, and discharge summary. This exceeds the limits imposed by 4 Pa. Code 255.5.
Client #5 was admitted on July 23, 2015 and was still an active client at the time of inspection. A consent to release form for the insurance company was signed by the client on July 23, 2015. The release form allowed for the release of assessments and evaluations, entire mental health record, summary of treatment, psychosocial history, and discharge summary. This exceeds the limits imposed by 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 03/01/3016, Facility Director will remove Mental Health release from charts, ensure D&A release is in all records; charts will be separated for dually diagnosed clients.
Clinical Supervisor will monitor this by checking charts every Friday. Facility Director will discuss during next Staff Meeting in March, and also check records monthly to remain in compliance. |