INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 27- 28, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run of York 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 and a plan of correction is due on March 25, 2008.
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Plan of Correction
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709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records on February 27 and 28, 2008, the facility failed to obtain an informed and voluntary consent from the client in two of four records reviewed, #2 and 4. Consents to release information forms were missing the specific information to be disclosed.
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Plan of Correction
Confidentiality will be reviewed in all staff meeting by Regional Administrator and Regional Office Manager on 4/7/08.
Medical Secretary will review all active charts for compliance, effective 3/23/08.
The BDAP approved Confidentiality Training will be scheduled as soon as possible; and all staff who provide treatment services will obtain the approved training within 365 days of hire. The Regional Administrator is responsible for ensuring compliance with the support from the QI department and the facility Medical Secretary.
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709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records on February 27 and 28, 2008, the facility failed to document the purpose of disclosure on the consent to release information forms in two of four records reviewed, #2 and 3.
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Plan of Correction
Confidentiality will be reviewed in all staff meeting by Regional Administrator and Regional Office Manager on 4/7/08.
Medical Secretary will review all active charts for compliance, effective 3/23/08.
The BDAP approved Confidentiality Training will be scheduled as soon as possible; and all staff who provide treatment services will obtain the approved training within 365 days of hire. The Regional Administrator is responsible for ensuring compliance with the support from the QI department and the facility Medical Secretary.
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709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records on February 27 and 28, 2008, the facility failed to document a complete personal history in three of three client records reviewed, #1, 2 and 3. Personal histories were missing information regarding the clients's family, legal, employment/vocational, educational, military, recreational and sexual histories.
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Plan of Correction
Clinical Supervisor will provide training to the nursing staff on documentation of personal histories and data collection. This will be completed by 4/7/08. This area was also reviewed in Nursing Leadership on 3/20/08. The clinical supervisor will audit 10 percent of records with the lead for 6 months to monitor compliance. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on February 27 and 28, 2008, the facility failed to document a complete psychosocial evaluation in two of three records reviewed, #1 and 5. Psychosocial evaluations did not include a composite picture of the client in relationship to the collected historical information in order to identify conditions and causes leading the client's current situation. Psychosocial evaluations (nursing assessment summary) contained client demographics and presenting problem(s), but failed to include an assessment of the client in relationship to the historical information gathered.
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Plan of Correction
Clinical Supervisor will provide training to the nursing staff on documentation of personal histories and Nursing Assessments for data collection. This will be completed by 4/7/08. This area was also reviewed in Nursing Leadership on 3/20/08. The clinical supervisor will audit 10 percent of records on a monthly basis, with the lead for 6 months to monitor compliance. |