INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 6-7, 2017, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of facility records conducted as part of the presubmission process and during the onsite inspection, the facility failed to include all of the required documentation in its fire drill records.
The fire drill records for 05/22/2016 and 11/23/2016 did not document whether or not the fire alarm or smoke detector was operative during the fire drill and the exit route used during the fire drill.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
1) Facility has added a Quality Improvement Coordinator position to work directly with the Health and Safety Officer to provide training to all staff responsible for documenting fire drills.
2) The process has been updated to include an immediate review of the documentation following each drill to ensure the documentation is completed accurately and in its entirety, with all pertinent information.
3) QI Coordinator will review drills conducted at the monthly Health & Safety Committee. If any drill documentation is not satisfactory, the drill will be conducted again during the month. |
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.
|
Observations
Based on a review of patient records conducted during the onsite inspection, the facility failed to include all of the required information on its signed consent to release information forms in 1 of 12 patient records reviewed.
The consent to release information to probation for patient #7 signed by the patient on 01/03/2017 did not document the purpose of the release.
The consent to release information to Medicaid for patient #7 signed by the patient on 01/03/2017 did not document the purpose of the release.
The consent to release information to the hospital for patient #7 signed by the patient on 01/03/2017 did not document the information to be released.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
1) Facility has revised the New Hire Orientation process to include having new hires practice completing a consent accurately during the training.
2) QI Coordinator will provide training to all new hires and existing staff responsible for completing consents with post-test assessment of competency.
3)Daily audits of each patient record will be conducted by the QI Coordinator or Charge Nurse to ensure consents are being completed accurately.
|
709.63(a)(7) LICENSURE Discharge summary
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:
(7) Discharge summary.
|
Observations
Based on a review of patient records conducted during the onsite inspection, the facility failed to document discharge summaries in 3 of 7 applicable detoxification records.
Patient #1 was discharged on 11/30/2016.
Patient #2 was discharged on 1/13/2017.
Patient #3 was discharged on 12/17/2016.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
1)All outstanding Discharge Summaries will be completed on each chart indicated as deficient.
2)Facility has hired a Case Manager position that will be trained to support the nursing staff with completing discharge summaries within 7 days of discharge.
2)QI Coordinator will audit a representative sample of charts for each month to ensure compliance. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
|
Observations
Based on a review of facility records conducted during the onsite inspection, the facility failed to verify the identity of 1 of 4 patients admitted for narcotic treatment.
Patient #3 was admitted for treatment on 12/14/2016 and discharged on 12/17/2016.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
1)QI Coordinator will provide training to the new Intake Technician and newly hired Nursing staff on the admission process and identity verification requirements for narcotic treatment.
2)Medication Administration Records will contain a copy of the patient ID obtained at admission to verify identity prior to dosing.
3) Daily audits will be conducted by the QI Coordinator or Charge Nurse to ensure compliance.
4) QI Coordinator will conduct quarterly audits on a representative sample to ensure compliance. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on review of patient records, the facility failed to follow the individualized treatment plan in 2 of 4 applicable records reviewed.
Patient #9 was admitted for residential treatment and rehabilitation on 08/02/2016 and was discharged from treatment on 08/12/2016. The patient's individualized treatment plan dated 08/05/2016 listed 6 groups counseling sessions per week, but the patient only had group counseling on 08/08/2016.
Patient #10 was admitted for residential treatment and rehabilitation on 09/27/2016 and was discharged from treatment on 10/11/2016. The patient's individualized treatment plan dated 09/30/2016 listed 6 groups counseling sessions per week, but the patient only had group counseling on 10/02/2016 and 10/06/2016.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
Clinical group counseling was provided 6 times per week, however, the assigned counselors failed to document each service provided in the patient records, despite patient attendance at the group. The assigned counselor also did not individualize the number of groups to be provided for each patient.
1)Clinical Coordinator will individualize each patient's treatment plan to indicate the number of group counseling services to be provided.
2) Clinical Coordinator will complete a DAP note for all clinical group services provided for each patient.
3) QI Coordinator will conduct an audit on a representative sample of charts for each month to ensure that group counseling services are being provided and documented according to the treatment plan. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
|
Observations
Based on a review of patient records conducted during the onsite inspection, the facility failed to document discharge summaries in 4 of 5 applicable residential treatment and rehabilitation records.
Patient #8 was discharged on 6/14/2016.
Patient #10 was discharged on 10/11/2016.
Patient #11 was discharged on 09/09/2016.
Patient #12 was discharged on 06/14/16.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
1) Discharge Summaries will be completed for all charts reviewed and identified with deficiencies.
2) Facility has hired a Case Manager position that will be trained to support the nursing staff with completing discharge summaries within 7 days of discharge.
3)QI Coordinator will audit a representative sample of charts for each month to ensure compliance.
|