Fairmount Behavioral issued second consecutive provisional license for repeat violations

Fairmount Behavioral Health’s inpatient unit was cited during a licensure inspection completed by the Pennsylvania Department of Human Services (DHS, formerly the Dept of Public Welfare) for repeat deficiencies related to adequate treatment, treatment plans, and patient rights. Fairmount Behavioral was issued a provisional license in December 2013 for the six month period from February 24, 2014 to August 24, 2014. However, upon this inspection, DHS found that the plan of correction items “were not implemented by the indicated implementation date of March 31, 2014.” DHS also noted that “as a result, repeat deficiencies were issued,” along with another provisional license for the six month period of August 24, 2014 to February 24, 2015. DHS found violations of adequate treatment regulations after it revealed “11 out of 11 charts reviewed did not have patient observation sheets that were completed by two staff person[s] at the end of each shift, as required by facility policy.” This was a repeat violation that was previously cited in December 2013. DHS also found repeat deficiencies while reviewing patient treatment plans. DHS noted that “5 out of 11 plans lacked evidence of consumer participation in treatment plan, updates, and amendments. Some plans were signed off on by psychiatrist and other team members prior to consumer reviewing and agreeing to plan.” DHS also reviewed medication rooms and medication administration record forms during the inspection. The inspection report noted the following repeat violations: • 13 out of 27 charts were missing required medication administration signatures • 5 out of 27 charts were missing required Accu-Chec results for blood sugar monitoring • 12 out of 27 charts did not have individual’s required vital signs documented DHS also found “PRN medications were prescribed, despite incomplete justification forms, for 3 out of 27 individuals. Also, PRN alternatives were not considered.” Fairmount Behavioral Health was issued another provisional license for a six month period ending February 24, 2015. The facility was required to submit a plan of correction to address these cited deficiencies.