INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine waiver monitorin that was conducted on March 18, 2015 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:
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report forms for all facilities within the drug and alcohol treatment project, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Report forms for the drug and alcohol treatment project's seventeen facilities were reviewed on March 2, 2015. The project employs a total of 106 full-time counselors and counselor assistants. This number of full-time counselors and counselor assistants would require a minimum of 13 full-time clinical supervisors. The project currently employs 8 full-time clinical supervisors, as of March 2, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Management, along with the Executive Director, will ensure there is one full-time clinical supervisor for every eight full-time counselors and counselor assistants. Caseloads will be redistributed by July 1, 2015 so that clinical supervisors who carry a caseload fall within the guidelines of chapter 704.6. Facility directors and clinical supervisors will be re-educated by the Quality Management Department on permissible case load sizes for each level of care.
Compliance will be accomplished by the facility director, along with the clinical supervisor(s), monitoring the number of full-time counselors vs. clinical supervisors on a quarterly basis.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill logs, the facility failed to document the completion of monthly unannounced fire drills. In addition, the facility failed to conduct a fire drill during sleeping hours at least every six months.
The findings include:
A review of the fire drill logs for the time period of January 2014 to December 2014 was conducted on March 18, 2015. The facility failed to document the completion of a monthly unannounced fire drill for October 2014 as well as document a second fire drill during sleeping hours as the only one conducted was on August 28, 2014.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The Health and Safety Officer will develop a yearly calendar for fire drills to ensure that drills are conducted on every shift, including during sleeping hours a minimum of every six months. All drills will be scheduled to occur prior to the 15th of the month. The Health and Safety Officer will submit the completed fire drill documentation to the Director within 24 business hours of completion of the drill. Drills that are not completed as scheduled by the 15th of the month will be rescheduled and conducted prior to month end. |
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 the review of client records, the facility failed to remain within the limits imposed by 4 Pa. Code 255.5 (b) in nine of ten records reviewed.
The findings included:
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Ten patient records were reviewed on March 18, 2015. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in client records 1, 3, 4, 5, 6, 7, 8, 9, and 10.
Client record #1 contained an Admission Pennsylvania Client Placement Criteria dated September 22, 2014 that allowed for the release of client's drug of choice which exceeds what is permissible under 4 Pa. Code 255.5.
Client record #3 contained an Admission Pennsylvania Client Placement Criteria dated October 23, 2014 that allowed for the release of client's drug of choice which exceeds what is permissible under 4 Pa. Code 255.5.
Client record #4 contained an Admission Pennsylvania Client Placement Criteria dated October 13, 2014 that allowed for the release of client's drug of choice which exceeds what is permissible under 4 Pa. Code 255.5.
Client record #5 contained an Admission Pennsylvania Client Placement Criteria dated October 27, 2014 that allowed for the release of client's drug of choice and medical condition which exceeds what is permissible under 4 Pa. Code 255.5.
Client record #6 contained an Admission Pennsylvania Client Placement Criteria dated October 14, 2014 that allowed for the release of client's drug of choice which exceeds what is permissible under 4 Pa. Code 255.5.
Client record #7 contained an Admission Pennsylvania Client Placement Criteria dated August 12, 2014 that allowed for the release of client's drug of choice and psychiatric diagnosis which exceeds what is permissible under 4 Pa. Code 255.5.
Client record #8 contained an Admission Pennsylvania Client Placement Criteria dated August 19, 2014 that allowed for the release of client's drug of choice and medical condition which exceeds what is permissible under 4 Pa. Code 255.5.
Client record #9 contained an Admission Pennsylvania Client Placement Criteria dated September 8, 2014 that allowed for the release of client's drug of choice and medical condition which exceeds what is permissible under 4 Pa. Code 255.5.
Client record #10 contained an Admission Pennsylvania Client Placement Criteria dated October 28, 2014 that allowed for the release of client's drug of choice which exceeds what is permissible under 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff responsible for providing patient care will be provided training on confidentiality laws and the limits pertaining to 4 Pa. Code 255.5. Clinical Supervisor and Nurse Manager will conduct monthly chart audits to ensure conformance to the confidentiality regulations. |