Fairmount Behavioral Health’s psychiatric unit was issued a provisional license after an inspection completed by the Pennsylvania Department of Human Services (DHS, formerly the Dept. of Public Welfare). During the inspection, the DHS found noncompliance with regulations, along with inadequate plans of correction, related to adequate treatment, treatment plans, release of information, properly completed forms, patient rights, and facility policies and procedures on patient restraints.
DHS cited the facility for violating adequate treatment regulations which required that “adequate treatment provided by an approved facility shall be designed on an individual basis under the relevant statues, regulations, and professional standards to promote the recovery from mental illness.” During the inspection, DHS found the following 3 items that did not meet regulations for adequate treatment:
1. 21 charts that “did not have patient observation sheets that were completed by two staff persons at the end of each shift, as required by facility policy.”
2. The facility “admitted Consumer A to the dual diagnosis unit, even though Consumer A did not have a substance abuse history. Staff did not address Consumer A’s complaint of feeling unsafe on the unit.”
3. “Consumer B, an adolescent, had an incident of inappropriate sexual contact. The chart showed no follow-up or treatment plan revisions.”
DHS also found 11 violations of patient rights regulations pertaining to medication and medication documentation. The inspection report noted the following items:
• PRN medications were prescribed despite incomplete justification forms
• Physician notes did not reconcile with medication orders and consents
• Physician notes did not contain rationale for medication changes and adjustments
• A consumer was allergic to two of the ordered medications
The inspection also revealed deficiencies in patient treatment plans. DHS found that “treatment plans were not reflective of assessments in addressing needs” and included the following:
• A consumer’s history of sexually inappropriate behavior was not taken into account, and their treatment plan was not amended following an incident
• Treatments plans were late and were not always dated by all members of the treatment team
• Plans lacked evidence of consumer participation. Plans were signed by psychiatrist prior to consumer reviewing and agreeing to treatment plan.
DHS also cited Fairmount Behavioral for deficiencies related to policies and procedures for restraint use, consensual release of information to third parties, and a FBI background clearance for one staff member.
The facility submitted a plan of correction in response to the cited deficiencies, but it was “partially accepted” by the Department of Human Services. A letter issued to the CEO of Fairmount Behavioral Health stated that the DHS’ “ Office of Mental Health and Substance Abuse Services is revoking the current Certificate of Compliance effective February 24, 2014 and is issuing the enclosed Provisional Certificate of Compliance for the six month period of February 24, 2014 to August 24, 2014.”