Fairmount Behavioral cited by State for issues relating to medications on patients' charts

Fairmount Behavioral Health System was cited during a licensing inspection conducted by the Pennsylvania Department of Human Services (DHS, formerly the Dept of Public Welfare) for deficiencies related to patient rights, adequate treatment, criminal record checks, policies and procedures, and release of information. During the DHS investigation, surveyors found 7 of 13 charts that “contained issues relating to medication” including the following: • Charts contained blanks on Medication Administration Records • One chart did not document the administration of an ordered PRN • Two charts indicated a first dose monitoring that was not completed • Two charts had multiple instances where administration of medication lacked but required two RN sign-off • Two charts had physician progress notes that did not reconcile with medication orders and consents • One chart reflected medication orders not being noted until the next day • One chart reflected a 7 day stop order that was ignored • PRN justification forms were incomplete DHS cited the facility for violations of adequate treatment regulations after finding that “8 of 13 charts contained instances in which observation sheet documentation: • Did not reconcile with progress notes • Did not reflect the appropriate protocol for shift hand off • Were blank in areas • Illegible • Did not contain the required signatures” DHS cited Fairmount for the having a Seclusion and Restraint policy that was not reflective of state regulations on the “use of Seclusion and Restraint in Mental Health Facilities and Programs.” DHS also found a staff person that “did not have a Pennsylvania State Police Criminal Record Check.” Lastly, DHS found 7 of 13 charts had “releases of information that were incomplete.” In the Provider’s Plan of Corrective Action, the facility agreed to address the cited deficiencies and revise the current seclusion and restraint policy. The provider was issued a 1 year Certificate of Compliance.