INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25, 2022, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of seven personnel records, the facility failed to hire one counselor that met both the educational and experience qualifications for the position.
Employee #6 was hired as a counselor on April 19, 2021 and was current in that position at the time of the inspection. Employee #6 had a qualifying bachelor ' s degree but did not have the full one year of clinical experience needed to qualify.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The HR Director and Facility Director will monitor each new hire for qualifications to ensure employees classified as a counselor will have at least one year of clinical experience (1,820 hours) in a health or human services agency, preferably in a drug and alcohol setting. In the event the employee's experience did not take place in a drug and alcohol setting, the employee's individual training plan will address a plan to achieve counseling competency for a drug and alcohol setting.
HR Director and Facility Director will monitor for compliance with each new clinical hire by reviewing education and experience.
Employee #6 will be placed into a counselor assistant position until they reach one year of clinical experience (1,820 hours) and achieve clinical competency for a drug and alcohol setting. This employee will receive weekly supervision until promoted to the position of counselor. The Clinical Supervisor will document and maintain evidence of supervision.
HR Director and Facility Director will monitor supervision logs to ensure compliance with the regulation.
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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 facility failed to obtain an informed and voluntary consent from the client for the disclosure of information that contained the specific information to be disclosed in three of the fourteen client records reviewed.
Client #6 was admitted on December 22, 2021 and was discharged on February 9, 2022. An informed and voluntary consent from the client for the disclosure of information was signed and dated on January 7, 2022, for the emergency contact that failed to document specific information to be disclosed.
Client #7 was admitted on September 7, 2021 and was discharged on September 27, 2021. An informed and voluntary consent from the client for the disclosure of information was signed and dated on September 13, 2021, to an outside agency that failed to document specific information to be disclosed.
Client #13 was admitted on January 13, 2022 and was discharged on January 18, 2022. An informed and voluntary consent from the client for the disclosure of information was signed and dated on January 13, 2022, to an outside agency that failed to document specific information to be disclosed.
These findings were discussed with Facility staff during the inspection process.
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Plan of Correction
The Quality Director will conduct Confidentiality/Consent training with employees responsible for completing consents (nursing, clinical, intake/admissions, case management). A sign in sheet will be completed and maintained for record.
Additionally, all staff responsible for completing consents will be required to take DDAP Confidentiality training on PA Train. 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.
Client #6 , #7 and #13 are no longer in treatment at the facility and consent is unable to be obtained.
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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 a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information that contained the purpose of disclosure in four of the fourteen client records reviewed.
Client #2 was admitted on December 28, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information was signed and dated on March 17, 2022, for an outside agency that failed to include the purpose of the disclosure.
Client #4 was admitted on February 23, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information was signed and dated on February 28, 2022, for an outside agency that failed to include the purpose of the disclosure.
Client #7 was admitted on September 7, 2021 and was discharged on September 27, 2021. An informed and voluntary consent from the client for the disclosure of information was signed and dated on September 13, 2021, to an outside agency that failed to include the purpose of the disclosure.
Client #13 was admitted on January 13, 2022 and was discharged on January 18, 2022. An informed and voluntary consent from the client for the disclosure of information signed and dated on January 13, 2022, to an outside agency that failed to include the purpose of the disclosure.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Quality Director will conduct Confidentiality/Consent training with employees responsible for completing consents (nursing, clinical, intake/admissions, case management). A sign in sheet will be completed and maintained for record.
Additionally, all staff responsible for completing consents will be required to take DDAP Confidentiality training on PA Train. 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.
Client # 2 #7 and #13 are no longer in treatment and consent is unable to be obtained. New, valid consents have been obtained to correct the consents for client #4.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include documentation that a copy of the consent was offered to the client in two of the fourteen client records reviewed.
Client #3 was admitted on February 24, 2022 and was still active at the time of inspection. An informed and voluntary consent from the client for the disclosure of information was signed and dated on March 15, 2022, to a county agency that failed to include documentation that a copy of the consent was offered to the client
Client #4 was admitted on February 23, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information was signed and dated on February 23, 2022, to an outside agency that failed to include documentation that a copy of the consent was offered to the client.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Quality Director will conduct Confidentiality/Consent training with employees responsible for completing consents (nursing, clinical, intake/admissions, case management). A sign in sheet will be completed and maintained for record.
Additionally, all staff responsible for completing consents will be required to take DDAP Confidentiality training on PA Train. 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.
New, valid consents have been obtained to correct the consents for client #3 and #4.
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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 a review of the facility ' s policy and procedure manual and seven client records, the facility failed to complete, and document follow up information in all three applicable client records reviewed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Facility Director will be retrain clinical staff on completion and documentation of follow up for each client record. Evidence of training will be maintained in the facility training files.
Random, monthly cart 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.
Client records that were reviewed during the onsite facility inspection have been corrected to reflect a completed follow up in each record.
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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 the facility ' s policy and procedure manual and seven client records, the facility failed to complete, and document follow up information in all three applicable client records reviewed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Facility Director will be retrain clinical staff on completion and documentation of follow up for each client record. Evidence of training will be maintained in the facility training files.
Random, monthly cart 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.
Client records that were reviewed during the onsite facility inspection have been corrected to reflect a completed follow up in each record.
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