INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 10-11th 2019 of White Deer Run York by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program 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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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
Based on a review of the project's policy and procedure manual, position descriptions, and an interview with facility staff, the project failed to ensure that the staff persons meet the educational and experiential qualification requirements of chapter 704. The position description for the Director of Program Management, also known as the Facility Director, does not include the requirement that the person have experience in program planning. The facility staff stated that their Counselor 2 position, was the equivalent of a counselor as per the Department of Drug and Alcohol Programs staffing regulations. However, the position description for a Counselor 2, only requires a high school diploma, and not an Associate degree or higher. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR department ensure the need for experience in program planning as a qualification for the Facility Director role will be added to the system's job description.
The line stating that a high school diploma is acceptable for a Counselor level position will be removed from the Counselor 2 job description by the HR manager. A line stating the education requirement for a counselor is a minimum of an associate's degree will be added by the HR manager.
The executive director's designee will review the project's policies and procedures against DDAP regulations annually to ensure compliance.
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709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy or procedure for utilization of volunteers.These findings were reviewed with facility during the licensing inspection.
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Plan of Correction
The executive director will create a policy in relation to volunteers for the system.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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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 must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of the project's policy and procedure manual, the project's confidentiality policy does not include 4 Pa. 255.5(a)(6) identifying the limitation of information that may be disclosed to employers or prospective employers of the client. In addition, project's policy and procedure manual does not identify the person responsible for maintaining electronic records. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will revise the confidentiality policy so it includes the limitation of information that may be disclosed to employers of the client.
The executive director will revise the confidentiality policy to include identification of the person responsible for maintaining electronic records.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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709.28 (a) (2) 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 must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
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Observations
Based on a review of the project's policy and procedure manual, the project's procedures do not address the methods by which staff gain access to electronic records.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will revise the confidentiality policy so it addresses the methods by which staff gain access to medical records.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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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 the review of seven client records, the facility failed to document a completed consent to release information in three records, as there were forms that were missing required information.Client #1 was admitted on April 8, 2019 and was still active at the time of the inspection. There was a consent to release forms, signed and dated on April 8th 2019 to the funding source, Probation, and PA Board of Probation and Parole but the consent form did not include what information could be released.Client #2 was admitted on April 8, 2019 and was still active at the time of the inspection. There was a consent to release forms, signed and dated on April 8th 2019 to the funding source, Probation, and PA Board of Probation and Parole but the consent form did not include what information could be released.Client #3 was admitted on November 19, 2018 and was discharged on November 24, 2018. There was a consent to release forms, signed and dated on November 21, 2018 to the an outside provider but the consent form did not include what information could be released.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Quality Improvement Manager will conduct a mandatory Confidentiality/Consent Training to all nursing and admission staff. Evidence of attendance will be maintained in the facility training files.
Chart reviews will be conducted on a monthly basis by the Chart to Charge Committee to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director.
Consents cannot be obtained on all seven records because the clients have since discharged from treatment. |
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 the review of seven client records, the facility failed to document a completed consent to release information in three records, as there were forms that were missing required information.Client #1 was admitted on April 8, 2019 and was still active at the time of the inspection. There was a consent to release forms, signed and dated on April 8th 2019 to the funding source, Probation, and PA Board of Probation and Parole but the consent form did not include the purpose of disclosure Client #2 was admitted on April 8, 2019 and was still active at the time of the inspection. There was a consent to release forms, signed and dated on April 8th 2019 to the funding source, Probation, and PA Board of Probation and Parole but the consent form did not include the purpose of disclosure.Client #3 was admitted on November 19, 2018 and was discharged on November 24, 2018. There was a consent to release forms, signed and dated on November 21, 2018 to the an outside provider but the consent form did not include the purpose of disclosure.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Quality Improvement Manager will conduct a mandatory Confidentiality/Consent Training to all nursing and admission staff. Evidence of attendance will be maintained in the facility training files.
Chart reviews will be conducted on a monthly basis by the Chart to Charge Committee to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director.
Consents cannot be obtained on all seven records because the clients have since discharged from treatment. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on the review of seven client records, the facility failed to document a completed consent to release information in one record, as there were forms that were missing required information.Client #1 was admitted on April 8, 2019 and was still active at the time of the inspection. There was a consent to release forms, signed and dated on April 8th 2019 to the county Probation officebut the consent form did not include the dated signature of witness. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Quality Improvement Manager will conduct a mandatory Confidentiality/Consent Training to all nursing and admission staff. Evidence of attendance will be maintained in the facility training files.
Chart reviews will be conducted on a monthly basis by the Chart to Charge Committee to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director.
Consents cannot be obtained on all seven records because the clients have since discharged from treatment. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the project's policy and procedure manual, the project failed to include in its policies that that the project may not discriminate in the provision of services based on age, ethnicity, marital status and/or creed.The Intake and Admission Continuum of Care Policy and Procedure for Intake and Admissions for Partial Hospital, Outpatient Part II and Adult Admission Criteria Part II, does not include age, ethnicity, and marital status for those who will not be discriminated against. The Intake and Admission Continuum of Care Policy and Procedure for Intake and Admissions for the Intake, Evaluation and Referral Activity does not include age, ethnicity, and marital status for those who will not be discriminated against. In the project's Rights Responsibilities and Ethics (RI), subject "Patients Rights" Policy and Procedure, Under Procedure: A. 1. "creed" is not included.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director will revise the patient rights so they include that the project may not discriminate in the provision of services based on age, ethnicity, marital status and/or creed.
The executive director will add "creed" to the Rights Responsibilities and Ethics subject "Patient Rights" policy and procedure A.1. section.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy or procedure for documentation of medication administration when self-administered by the client.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will revise the current policy that exists on medication administration and self-administration so it includes reference to the current self medication documentation form.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy relating to maintaining copies of drug-related regulations being available in appropriate areas.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will add a policy that addresses the need to maintain copies of drug-related regulations in appropriate areas to the regional policy and procedure manual.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Based on a review of the project ' s policy and procedure manual, the project does not have a procedure in place to address the requirements in 715.22(b).The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director will revise the current grievance procedure so it addresses permitting patients to have a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director and to address grievances filed by patients against the narcotic treatment program director.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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715.22(c) LICENSURE Patient grievance procedures
(c) Penalties may not be initiated prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to commit acts of physical violence in or around the narcotic treatment program premises.
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Observations
Based on a review of the project ' s policy and procedure manual, the project does not have a procedure in place to address the requirements in 715.22(c ). The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director will update the grievance procedure to address penalties being initiated against patients prior to the final resolution of grievances.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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