INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on March 9, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for facility directors.
Employee #2 was hired as a facility director on February 3, 2019 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2022 through December 31, 2022. Employee # 2's record only document 10:48 hours of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility will assign a staff member to monitor training hours on site. The new Training Coordinator will keep track of all trainings completed by staff at the facility. A binder will be kept at the facility containing all training certificates with a tracker to monitor for hours.
The training Coordinator will ensure all training certificates and evaluations are sent to the Quality Director. When staff are running low on training hours, the Quality Director will alert the staff's supervisor. The staff's supervisor will meet with the staff member and review training options to ensure compliance with 704.11
Quality Director will audit training hours on a quarterly basis to ensure compliance. Quality Director will send compliance reports to the Regional Program Director.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from March 28, 2022 through February 28, 2023, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. A fire drill during sleeping hours was completed on June 13, 2022 and then not again until January 31, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility safety officer will coordinate a sleeping fire drill at a minimum of every six months. The facility safety officer will review and monitor fire drill log on a monthly basis.
The safety officer will send fire drill reports to the Quality Director on a quarterly basis. Quality Director will monitor for compliance.
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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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form to include purpose in three out of eleven records reviewed.
Client #4 was admitted on February 27, 2023 and was still active at the time of the inspection.
Client #10 was admitted on September 12, 2022 and discharged on October 11, 2022.
Client #11 was admitted on December 2, 2022 and discharged on January 19, 2023.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the March 25, 2022 licensing inspection.
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Plan of Correction
Within 30 days of hire, staff responsible for completing consents will receive one on one training with their supervisor on how to properly complete a consent. Competency assessment will be completed after the training.
All staff responsible for completing consents will be required to take DDAP Confidentiality training on PA Train within the first 180 days of hire. Training certificates will be maintained in employee training files.
Quality Director will conduct confidentiality training during all new employee orientation trainings, which will include training on how to complete a consent. New employee orientation will occur on a monthly basis, as needed.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
Clients #4, 10 and 11 have already been discharged and consent cannot be completed.
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to verify an emergency contact in two out of six records reviewed.
Patient #1 was admitted on March 4, 2023 and was still active at the time of the inspection.
Patient #4 was admitted on February 27, 2023 and discharged on March 4, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
one on one training with their supervisor on how to obtain an emergency consent for those clients who are going to be receiving MAT.
All staff responsible for completing consents are required to take DDAP Confidentiality training within the first 90 days of hire. Training certificates will be maintained in employee training files.
Quality Director will conduct confidentiality training during all new employee orientation trainings, which will include training on how to complete a consent. New employee orientation will occur on a monthly basis, as needed.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
Patient #1 was admitted on March 4, 2023 and discharged March 11, 2023 therefore a valid consent is unable to be obtained.
Patient #4 was admitted on February 27, 2023 and was discharged on March 4, 2023 therefore a valid consent is unable to be obtained.
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of the patient records, the facility failed to ensure that prior to administration of an agent, a narcotic treatment physician documented in the patient's record the basis for the determination of current dependency and evidence of a one year history of addiction.
Patient #3 was admitted on February 22, 2023 and discharged on March 4, 2023. Patient #3 was administered her first dose of an agent on March 1, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The physician will complete the Opiate Dependency Criteria Checklist indicating whether or not the client is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least one year prior to admission for maintenance treatment. This will be completed for all clients entering the treatment program.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in one out of three applicable records reviewed.
Client #8 was admitted on January 25, 2023 and was still active at the time of the inspection. A treatment plan was completed on January 25, 2023 and the next update was due no later than February 25, 2023; however, none had been completed as of the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors will ensure Treatment and rehabilitation plans are reviewed and updated at least every 30 days.
The Clinical Supervisor will add Treatment Plan Update due dates to the Case List tracking, which will be distributed to clinicians on a daily basis.
The Clinical Supervisor will review active client records with Counselors during supervision to ensure treatment plan updates are completed and in a timely fashion.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
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709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of three discharged records reviewed.
Client #9 was admitted on November 9, 2022 and was discharged on December 9, 2022.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counseling and/or Case Management will complete a follow up on all clients discharged from the facility. The follow up will be completed no later than 30 days after discharge. Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
Chart #9 record has been corrected to reflect a completed follow up.
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