INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10, 2021 through March 11, 2021 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of personnel and training records, the project failed to ensure that the clinical supervisor, who has not functioned for two years as a supervisor in the provision of clinical services shall complete a core curriculum in clinical supervision.Employee #3 was hired as a clinical supervisor on June 8, 2020. There was no documentation in the personnel record indicating that the employee had either functioned as a supervisor in the provision of clinical services or competed a core curriculum in clinical supervision. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will schedule and attend DDAP approved Clinical Supervision Training on May 24th through May 28th, 2021.
Quality Director and HR will maintain a copy of the training certificate in the employee's training file.
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of personnel records and supervision logs, the project failed to ensure that the clinical supervisor participate in documented monthly meetings with their supervisor for the first six months of employment in the clinical supervision position.Employee #3 was hired as a clinical supervisor on June 8, 2020 and was and active employee at the time of the inspection. There was no documentation of monthly supervision meetings for the months of June 2020, August 2020, October 2020 and November 2020.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Facility Director will meet with Clinical Supervisor on a monthly basis for the next six months to discuss duties and performance. Frequency of the meetings will be assessed at conclusion of the six months. Documentation of the meetings will be maintained in the Clinical Supervisor's file.
Quality Director will monitor for compliance on a quarterly basis.
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704.8(a) LICENSURE Qualifications-Counselor Assistant
704.8. Qualifications for the position of counselor assistant.
(a) A person who does not meet the educational and experiential qualifications for the position of counselor may be employed as a counselor assistant if the requirements of at least one of the following paragraphs are met. However, a project may not hire more than one counselor assistant for each employee who meets the requirements of clinical supervisor or counselor.
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Observations
Based on the review of personnel records and the Staffing Requirement Facility Summary report, the project failed to not hire more than one counselor assistant for each employee who meets the requirements of clinical supervisor or counselor.At the time of the inspection, the facility employed five counselor assistants, one clinical supervisor and one counselor.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The HR Director and Facility Director will only employ one counselor assistant for each Counselor or Clinical Supervisor.
Three of the Counselor Assistants have been re-assigned as Behavioral Health Associates and one Counselor Assistant resigned.
HR Director and Quality Director will monitor for compliance with each new clinical hire.
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on the review of personnel records and supervision logs, the project failed to document close supervision for at least the first six-months of employment for one counselor assistant with a qualifying bachelor ' s degree. Additionally, the project failed to document direct observation for the first three-months of employment, followed by close supervision for the remaining nine-months for three counselor assistants with a high school diploma.Employee #4 was hired as a counselor assistant with a high school diploma on November 18, 2020 and was to receive director observation until February 18, 2021 and close supervision (one hour of weekly direct observation and one hour of weekly case review) thereafter. There was no documentation of direct observation occurring for the first three months of employment.Employee #6 was hired as a counselor assistant with a high school diploma on October 9, 2020 and was to receive director observation until January 9, 2021 and close supervision (one hour of weekly direct observation and one hour of weekly case review) thereafter. There was no documentation of direct observation occurring for the first three months of employment, nor was documentation of close supervision occurring thereafter. Employee #7 was hired as a counselor assistant with a qualifying Bachelor ' s Degree on October 18, 2020 and is to receive close supervision (one hour of weekly direct observation and one hour of weekly case review) until April 18, 2021. There is no documentation of close supervision for the weeks of November 1, 2020 through November 7, 2020, November 15, 2020 through November 21, 2020 and for the months of December 2020, January 2021 and February 2021.Employee #8 was hired as a counselor assistant with a high school diploma on December 19, 2020 and is to receive director observation until March 19, 2021 and close supervision (one hour of weekly direct observation and one hour of weekly case review) thereafter. There was no documentation of direct observation occurring for the first three months of employment.These findings were reviewed with project staff during the licensing process.This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
The Clinical Supervisor will ensure Counselor Assistants with a Bachelor's Degree will receive documented, close supervision for at least the first six-months of employment by a trained counselor or Clinical Supervisor.
The Clinical Supervisor will ensure Counselor Assistants with a High School Diploma will receive documented, direct observation for the first three-months of employment, followed by close supervision for the remaining nine-months of employment.
HR Director and Quality Director will monitor for compliance on a quarterly basis.
Three of the Counselor Assistants have been re-assigned as Behavioral Health Associates and one Counselor Assistant resigned.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of eight personnel records, the project failed to document an individual training plan for three employees within the first 30-days of employment.Employee #3 was hired on June 8, 2020 and was to have an individual training plan documented by July 8, 2020; however, there was no training plan documented in the personnel record until November 18, 2020.Employee #4 was hired on November 18, 2020 and was to have an individual training plan documented by December 18, 2020; however, there was no training plan documented in the personnel record until March 4, 2021.Employee #6 was hired on October 9, 2020 and was to have an individual training plan documented by November 9, 2020; however, there was no training plan documented in the personnel record until November 19, 2020.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Each new hire will complete an individual training plan with their supervisor no later than 30 days after hire.
HR Director and Quality Director will monitor for compliance.
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709.28 (c) 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.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of ten client records reviewed.Client #1 was admitted on March 6, 2021 and was a current client at the time of the inspection. There was communication between staff and a drug and alcohol scholarship funding program documented in the record on March 9, 2021; however, there was no release of information form documented in the record prior to the disclosure.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
All staff responsible for completing consents (nursing, clinical, admissions and intake staff) will attend the DDAP Confidentiality training by June 1, 2021. Certificate of attendance will be maintained in each training file.
Quality Director will hold an in-service training to be attended by staff responsible for completing consents (nursing, clinical, admissions and intake staff) at least once per month on confidentiality and proper completion of consents beginning April 1, 2021.
Monthly chart audits will be completed by nursing, clinical, admissions and intake staff to monitor for compliance. Results of monthly chart audits will be shared with Facility Director and Quality Director.
The consent for Client #1 is unable to be obtained due to client has discharged.
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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 must 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, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of ten client records reviewed. Additionally, the project failed to document the specific information to be disclosed in two of ten client records reviewed.Client #5 was admitted on February 19, 2021 and discharged on February 23, 2021. A release of information form to the clients employer, signed and dated by the client on February 19, 2021 which allowed for the release of the diagnosis, a brief description of progress and prognosis, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, six release of information forms, three to local hospitals, one to a pharmacy, one to the funding source and one to a probation agency, signed and dated by the client on February 19, 2021, did not document the specific information to be disclosed.Client #7 was admitted on December 5, 2020 and was discharged on December 12, 2020. Two release of information forms, one to a state probation agency and the other to a county probation agency, signed and dated by the client on December 4, 2020, did not document the specific information to be disclosed.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
All staff responsible for completing consents (nursing, clinical, admissions and intake staff) will attend the DDAP Confidentiality training by June 1, 2021. Certificate of attendance will be maintained in each training file.
Quality Director will hold an in-service training to be attended by staff responsible for completing consents (nursing, clinical, admissions and intake staff) at least once per month on confidentiality and proper completion of consents beginning April 1, 2021.
Monthly chart audits will be completed by nursing, clinical, admissions and intake staff to monitor for compliance. Results of monthly chart audits will be shared with Facility Director and Quality Director.
Consent for client #5 is unable to be obtained due to client has discharged.
Consent for client #7 is unable to be obtained due to client has discharged.
The additional six releases that did not document the specific information to be disclosed cannot be obtained due to the clients have discharged.
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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 project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in four of ten client records reviewed.Client #1 was admitted on March 6, 2021 and was a current client at the time of the inspection. A release of information form to a recovery house, signed and dated on March 9, 2021, did not document the purpose of disclosure.Client #4 was admitted on January 11, 2021 and was discharged on January 17, 2021. A release of information form to a district judge, signed and dated on January 15, 2021, did not document the purpose of disclosure.Client #5 was admitted on February 19, 2021 and was discharged on February 23, 2021. Six release of information forms, three to local hospitals, one to a pharmacy, one to the funding source and one to a probation agency, signed and dated by the client on February 19, 2021, did not document the purpose of disclosure.Client #7 was admitted on December 5, 2021 and discharged on December 12, 2021. Two release of information forms, one to a state probation agency and the other to a county probation agency, signed and dated on December 4, 2020, did not document the purpose of disclosure.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
All staff responsible for completing consents (nursing, clinical, admissions and intake staff) will attend the DDAP Confidentiality training by June 1, 2021. Certificate of attendance will be maintained in each training file.
Quality Director will hold an in-service training to be attended by staff responsible for completing consents (nursing, clinical, admissions and intake staff) at least once per month on confidentiality and proper completion of consents beginning April 1, 2021.
Monthly chart audits will be completed by nursing, clinical, admissions and intake staff to monitor for compliance. Results of monthly chart audits will be shared with Facility Director and Quality Director.
Consent for client #1 is unable to be obtained due to client has discharged.
Consent for client #4 is unable to be obtained due to client has discharged.
Consent for client #5 is unable to be obtained due to client has discharged.
Consent for client #7 is unable to be obtained due to client has discharged.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated client signature in one of ten client records reviewed.Client #6 was admitted on November 23, 2020 and was discharged on November 26, 2020. A release of information form for a probation agency, signed and dated by a witness on November 23, 2020, did not have a client signature documented on it.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
All staff responsible for completing consents (nursing, clinical, admissions and intake staff) will attend the DDAP Confidentiality training by June 1, 2021. Certificate of attendance will be maintained in each training file.
Quality Director will hold an in-service training to be attended by staff responsible for completing consents (nursing, clinical, admissions and intake staff) at least once per month on confidentiality and proper completion of consents beginning April 1, 2021.
Monthly chart audits will be completed by nursing, clinical, admissions and intake staff to monitor for compliance. Results of monthly chart audits will be shared with Facility Director and Quality Director.
Consent for client #6 is unable to be obtained due to client has discharged.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two applicable client records reviewed.Client # 8 was admitted on February 6, 2021 and was involuntarily terminated from treatment on February 8, 2021.Client #10 was admitted on January 13, 2021 and was involuntarily terminated from treatment on January 16, 2021.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Quality Director will review the organization's policy on termination of treatment with nursing and clinical staff to ensure understanding of policy and required documentation including notification to the client, in writing, of the decision to terminate client's treatment and the reason for the termination. Review will be held no later than June 1, 2021.
Monthly chart audits will be completed by nursing and clinical to monitor for compliance. Results of monthly chart audits will be shared with Facility Director and Quality Director.
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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 the review of client records, the project failed to document a psychosocial evaluation in seven of ten client records reviewed.Client #1 was admitted on March 6, 2021 and was a current client at the time of the inspection.Client #2 was admitted on March 6, 2021 and was a current client at the time of the inspection.Client #3 was admitted on October 21, 2020 and was discharged on October 26, 2020.Client #4 was admitted on January 11, 2021 and was discharged on January 17, 2021.Client #7 was admitted on December 5, 2020 and was discharged on December 12, 2020.Client # 8 was admitted on February 6, 2021 and was discharged on February 8, 2021.Client #10 was admitted on January 13, 2021 and was discharged on January 16, 2021.These findings were reviewed with project staff during the licensing process.This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
Effective March 29, 2021 after completing the nursing assessment, nursing staff began completing the detox addendum, which serves as the psychosocial evaluation for clients being admitted to 3.7 WM level of care.
Monthly chart audits will be completed by nursing, clinical, admissions and intake staff to monitor for compliance. Results of monthly chart audits will be shared with Facility Director and Quality Director.
The psychosocial evaluation is unable to be completed on client #1, 2, 3, 4, 7, 8 and 10 due to clients have discharged.
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715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on the review of patient records, the program failed to ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment in one of four applicable patient records reviewed.Patient # 7 was admitted on December 5, 2020 and was discharged on December 12, 2020.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The facility nursing staff will screen/test all female patients for pregnancy upon admission to the Buprenorphine Detoxification Program to determine if the patient is pregnant. If the test is positive, the client will not be considered for detoxification using buprenorphine. All women will be informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment. If the patient agrees, a referral will be made to a 3.7 WM facility that treats pregnant women. If the patient does not wish to transfer, the patient will be advised of the process to make a referral to a Methadone Maintenance Program/Buprenorphine Maintenance Program in her home area. The appropriate staff will obtain appropriate consents, make the referral and discharge arrangements with the patient's involvement.
CRNP will monitor for compliance with each new admission.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on the review of patient records, the program failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment in one of four patient records reviewed.Patient # 7 was admitted on December 5, 2020 and was discharged on December 12, 2020. An informed, voluntary, written consent was not documented in the patient record.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Upon admission into the OTP program, the nursing staff will review the Buprenorphine Informed Consent, which states that Buprenorphine is a narcotic drug which can be harmful if taken without medical supervision, and is an addictive medication and may, like other drugs used in medical practices, produce adverse results. The consent also states alternative methods of treatment exist and the possible risks and complications of treatment have been explained to the client. The consent will also inform the client that Buprenorphine is transmitted to the unborn child and will cause physical dependence.
Monthly chart audits will be completed by nursing to monitor for compliance. Results of monthly chart audits will be shared with Facility Director and Quality Director.
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