INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and inspection conducted for the approval to use a narcotic agent, specifically Buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on March 15, 2016 by staff from the Department of Drug and Alcohol Programs Licensure Division. 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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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on an observation during the physical plant inspection, the facility failed to keep frozen food at or below 0 degrees fahrenheit in two of two freezers.
The findings include:
A physical plant inspection was conducted on March 15, 2016 at approximately 9:30 am.
A freezer holding food that is located in the kitchen, had a thermometer that read 30 degrees fahrenheit. Additionally a freezer holding food that is located in the pantry room, had a thermometer that read 35 degrees fahrenheit. A second inspection took place in the afternoon where it was observed the freezer holding food that is located in the pantry room, had a thermometer that read 9 degrees fahrenheit.
Licensing specialist requested the facility's daily freezer temperature log book. Facility director could not provide documentation of the facility's daily freezer temperature logs from February 9, 2015 to the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each freezer will have the temperature recorded twice per day to ensure that the equipment is functioning within the required degrees. The cook will be responsible for recording the temperatures at the start of each shift and at the end of each shift. Any recordings outside of the identified range will be immediately evaluated for any necessary repairs. Program Director will conduct audits of the temperature logs to ensure compliance with this process. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of a fire extinguisher upon staff employment, in one of five personnel records reviewed.
The findings include:
Five personnel records were reviewed on March 15, 2016. The facility failed to document the instruction of staff in the use of a fire extinguisher upon staff employment for employee #5.
Employee #5 was hired on January 11, 2016. The instruction of staff in the use of fire extinguisher was not documented until February 2, 2016.
These findings were reviewd with facility staff during the licensing process.
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Plan of Correction
All employees will receive Fire and Safety training for use of a fire extinguisher on the first day of employment. This will be incorporated into the Job Specific Orientation form with a required completion date for day one of orientation. Program Director will monitor compliance with this process through collection of all completed training certificates directly following each new hire's first day of employment. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff to perform assigned tasks during emergencies in one of five personnel records.
The findings include:
Five personnel records were reviewed on March 15, 2016. The facility failed to document the completion of emergency training in personnel record #5.
Employee # 5 was hired on January 11, 2016. Emergency training was not documented until February 2, 2016
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All new employees will recieve emergency training on the first day of employment. This training will be incorporated into the Job Specific Orientation form with a required completion date of the first day of employment. Program Director will monitor compliance with this requirement through collection of the training certificates directly following the employee's first day of work. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills were accurately documented on the fire drill reports.
The findings include:
The fire drill record was reviewed on March 15, 2016. Twelve months of fire drills were reviewed from the date of the last licensing inspection, 3/18/15. The facility's hours of operation are 24 hours a day, seven days a week.
The facility failed to document the time the fire drill took place for 06/28/15, 5/29/15 and 10/29/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility staff will be provided training on the proper completion of the fire drill documentation to ensure thorough completion of all pertinent information on the form. Program Director will monitor compliance with this requirement by collecting and reviewing all fire drill documentation following each drill so that errors may promptly be addressed and drills repeated if necessary. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent in eight of fifteen client records.
The findings include:
Fifteen client records were reviewed on March 15, 2016. The facility's consent to release client information was observed to be out of compliance with 42 CFR and State Law 4 Code 255.5 (b) in client records, #1, 4, 8, 9, 11, 12 and 15.
In addition, the "Authorization for Release of Information" form did not contain documentation of the client's right to verbally revoke a signed consent for the release of information. The facility's "Authorization for Release of Information" form documented, "I may revoke this authorization at any time. Revocations to this authorization must be presented in writing."
Client #1 was admitted on February 28, 2016, and was still an active client at the time of inspection. Consent forms dated 2/24/16 allowed for the release of the client's alcohol, drug, or substance abuse records, HIV testing and results, and mental health records to funding sources. In addition, the facility failed to comply with 42 CFR as the consent only allowed the client to revoke their consent forms in writing.
Client #2 was admitted on February 26, 2016 and was still an active client at the time of inspection. The facility failed to comply with 42 CFR as the consents only allowed the client to revoke their consent forms in writing.
Client #4 was admitted on January 20, 2016 and was discharged on February 15, 2016. Consent forms dated 1/20/16, the facility failed to check off the purpose of the disclosure and what was to be released. In addition, the facility failed to comply with 42 CFR as the consents only allowed the client to revoke their consent forms in writing.
Client #8 was admitted on March 11, 2016, and was still an active client at the time of inspection. Consent forms dated 3/11/16 allowed for the release of the client's alcohol, drug, or substance abuse records, HIV testing and results, and mental health records to funding sources. In addition, the facility failed to comply with 42 CFR as the consent only allowed the client to revoke their consent forms in writing.
Client #9 was admitted on March 14, 2016, and was still an active client at the time of inspection. Consent forms dated 3/14/16 allowed for the release of the client's alcohol, drug, or substance abuse records, HIV testing and results, and mental health records to funding sources. In addition, the facility failed to comply with 42 CFR as the consent only allowed the client to revoke their consent forms in writing.
Client #11 was admitted on March 12, 2016, and was still an active client at the time of inspection. Consent forms dated 3/12/16 allowed for the release of the client's alcohol, drug, or substance abuse records, HIV testing and results, and mental health records to funding sources and government agencies. In addition, the facility failed to comply with 42 CFR as the consent only allowed the client to revoke their consent forms in writing.
Client #12 was admitted on March 9, 2016, transferred to inpatient rehab on March 15, 2016, and was still an active client at the time of inspection. Consent forms dated 3/9/16 allowed for the release of the client's alcohol, drug, or substance abuse records, HIV testing and results, and mental health records to funding sources. In addition, the facility failed to comply with 42 CFR as the consent only allowed the client to revoke their consent forms in writing.
Client #15 was admitted on February 16, 2016, transferred to inpatient rehab February 21, 2016 and was still an active client at the time of inspection. Consent forms dated 2/16/16 allowed for the release of the client's alcohol, drug, or substance abuse records to funding sources. In addition, the facility failed to comply with 42 CFR as the consent only allowed the client to revoke their consent forms in writing.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff responsible for completing consent forms with patients will be provided additional training on proper procedure for completing the consents to ensure the consent is valid. An additional line will be added to consents indicating the consent can be revoked verbally. All current clients will resign new consents with this added verbage. Nurse Manager will ensure that chart audits are completed on all new admissions to verify consents are completed correctly. Quality Manager is working with corporate to make changes to the consent document which will permanently address the issue. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in three of eleven client records reviewed.
The findings include:
Eleven client records were reviewed for counseling services during the renewal inspection on March 15, 2016. The project failed to ensure that clients received counseling services according to the client's individual treatment and rehabilitation plan in client records # 1, 4, and 6.
Client # 1 was admitted to the facility on February 28, 2016 and was still an active client at the time of inspection. Client #2's record contained a treatment plan dated 3/4/16 that identified the counseling services to be provided as individual therapy once per week and group therapy six times per week. The record did not contain documentation of any individual sessions from 3/6/2016 - 3/12/2016.
Client #4 was admitted to the facility on January 20, 2016 and discharged on February 15, 2016. Client #4's record contained a treatment plan dated 1/26/16 that identified the counseling services to be provided as individual therapy once per week and group therapy four times per week. The record did not contain documentation of any individual sessions from 1/31/16-2/6/2016. For that same week, the client only received two group counseling sessions. Additionally the record did not contain documentation of any individual or group sessions from 2/7/2016-2/14/2016.
Client #6 was admitted to the facility on September 23, 2015 and discharged on October 14, 2015. Client #6's record contained a treatment plan dated 9/25/15 that identified the counseling services to be provided as individual therapy once per week and group therapy four times per week. The record did not contain documentation of any individual sessions from 10/2/2015-10/9/2015.
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Plan of Correction
Frequency of counseling services, both group and individual, will be properly documented on the record of services form in each patient's chart. A corresponding DAP note will be completed and filed within 24 hours of the service provided. Clinical Supervisor will conduct weekly open chart audits to ensure that all services provided have been properly documented. |