INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24, 2011 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 April 26, 2011.
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Plan of Correction
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all counseling sessions could not be seen from outside of the counseling room.
A physical plant inspection was conducted on March 24, 2010 at 1:15 PM..
During the physical plant inspection it was found that the two group rooms both had large uncovered windows in which a counseling session could be seen from outside of the room.
This was confirmed with the facility director during the inspection.
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Plan of Correction
The facility will continue to maintain the current policy regarding counseling sessions held in the client lounge areas. Current policy is that the general public does not have access to that area of the building, client privacy is ensured in that only clients and facility staff are allowed in the lounges, hallways, patient rooms, and nursing station areas at any time of the day. Counseling sessions are not visible to the general public. Additionally, as the facility is owned by the County of York, we have contacted the County maintenance supervisor on 4/1/11. He is responsible for maintenance oversight of the facility and we have advised him of the deficiency. He has responded that the County contracts with a vendor to make and install custom blinds and shades. He has agreed to contact his vendor and to have the vendor correct the deficiency by fabricating and installing blinds on the interior hallway windows. We anticipate this process to be completed by 5/1/2011. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on the review of client records, the facility's policy and procedure manual, and a conversation with the facility director, the facility failed to document follow-ups in accordance with the facility's policies and procedures.
The findings include:
Four detox records were reviewed on March 24, 2011. Documentation of a follow-up was required in two of those records. The facility failed to document a follow-up information to the referral source in accordance with the facility's policies and procedures in one of two records reviewed, specifically, client record #9.
The facility's follow-up policy states:
When a client is discharged and referred to an outside resource, the facility will contact the resource within one week from the date the referral is to be completed. If a client is not referred, the facility will attempt to contact the client within four weeks.
Client # 9 was admitted on August 25, 2010 and discharged on September 1, 2010. Upon discharge, the client was referred to an outside source. The appointment was scheduled for October 22, 2010. A follow up attempt should have been made to the referral source by October 29, 2010 but instead a follow-up attempt had been made to the client on November 10, 2010.
The follow-up attempt had been confirmed with the facility director.
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Plan of Correction
Client follow-ups will be completed within the timeframes prescribed in the facility policy and according to the procedure outlined within the policy. Staff will be re-trained on the policy at the April 20th staff meeting. Counselors and/or nursing staff are required to communicate aftercare referrals to the staff member who conducts the client follow up to ensure the process is completed within the allowable timeframes and with the appropriate person (i.e. client or referral agency). The Nursing Coordinator and Clinical Director will routinely monitor on a daily basis that the appropriate information is being shared in the shift report meetings. Completed follow-up forms will also be reviewed by administrative supervisors on a weekly basis to ensure completion in accordance with the policy. |