INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 20, 2010 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 May 15, 2010.
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Plan of Correction
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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.
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Observations
Based on a review of client records, facility policy, and staff interviews, the facility failed to document a discharge summary in one of two client records.
The findings include:
Five client records were reviewed on April 14, 2010. Two of the client records reviewed required discharge summaries. The facility did not document a discharge summary in one of two client records.
Client #4 was admitted on 11/28/09 and discharged on 12/3/09. There was no documentation of a discharge summary in the client record.
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Plan of Correction
Clinical staff will be re-trained during the May department meeting to review the proper procedure for completing and filing discharge summary reports. Additionally, the Clinical Supervisor will continue to conduct random on-going chart reviews each week to ensure discharge summaries are completed in a timely manner and that charts are being audited properly by the administrative technician. An administrative technician position has been advertised and will be hired to conduct on-going internal chart reviews and perform an internal audit function to ensure all applicable paperwork is completed on-time and documented properly which will include the discharge summary. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, facility policy, and staff interviews, the facility failed to document physical examinations in one of three client records.
The findings include:
Five records were reviewed on April 20, 2010. Physical examinations were required in three client records. In client record # 3 the client was admitted on March 29, 2010 directly to the inpatient non-hospital residential treatment facility. There was no documentation of a physical examination in the client record.
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Plan of Correction
The facility Nurse Manager has conducted a training session with all facility nursing staff on 5/4/2010 and re-trained all the nursing staff on the proper procedure and protocol for scheduling client physical examinations by the facility physician. Facility management has reviewed the procedure for scheduling patients for physical examinations and has made a change in the morning report so that physicals can be monitored more closely on a daily basis beginning immediately. Patients scheduled to receive physicals will be documented on the morning report so that it can be compared to the daily admissions report to ensure all new admissions are on the doctor schedule to receive an H&P within the prescribed timeframe. Once hired, the administrative technician will also monitor for on-going compliance |