INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 24, 2018 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The facility failed to conduct a fire drill during sleeping hours at least once every six months.Fire drill logs for January - December, 2017 and January- March, 2018 were reviewed on April 24, 2018. An overnight fire drill was documented on March 3, 2017. The next documented overnight fire drill was November 28, 2017. These finding were reviewed with facility staff during the licensing inspection.
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Plan of Correction
White Deer Run of York will conduct a fire drill during sleeping hours twice a year and no later than six months from the last sleeping hours fire drill.
White Deer Run of York Quality Improvement Coordinator will monitor all drills for compliance.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to document an annual written individual staff performance evaluation in one of three personnel records reviewed on April 24, 2018. In personnel record # 2, there was no documentation provided of a 2017 annual evaluation. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
White Deer Run of York leadership will review upcoming annual performance evaluations and complete them with employees on a monthly basis.
Completed annual performance evaluations will be sent to the HR department to be filed in the employee's personnel record.
White Deer Run HR Department will monitor for compliance.
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715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The narcotic treatment program failed to have a narcotic treatment physician make a face-to face determination in six of seven records reviewed on April 24, 2018. In patient records #1, 2, 4, 5, 6 and 7, the CRNP completed the face to face determination. Inpatient record # 1, the face to face was completed by the CRNP on April 20, 2018 and the patient was initially dosed on April 20, 2018. The narcotic treatment physician signed off on the face to face completed by the CRNP on April 21, 2018. There was no documentation that the patient was seen face to face by the narcotic treatment physician prior to initial dose. Inpatient record # 2, the face to face was completed by the CRNP on April 21, 2018 and the patient was initially dosed on April 21, 2018. The narcotic treatment physician signed off on the face to face completed by the CRNP on April 22, 2018. There was no documentation that the patient was seen face to face by the narcotic treatment physician prior to initial dose. Inpatient record # 4 the face to face was completed by the CRNP on October 8, 2017. The patient was initially dosed on October 9, 2017. The narcotic treatment physician signed off on the face to face completed by the CRNP on October 9, 2017. There was no documentation that the patient was seen face to face by the narcotic treatment physician prior to initial dose. Inpatient record # 5 the face to face was completed by the CRNP on March 6, 2018. The patient was initially dosed on March 7, 2018. The narcotic treatment physician signed off on the face to face completed by the CRNP on March 7, 2017. There was no documentation that the patient was seen face to face by the narcotic treatment physician after initial dose. Inpatient record # 6 the face to face was completed by the CRNP on January 5, 2018. The patient was initially dosed on January 5, 2018. There was no documentation that the narcotic treatment physician signed off on the face to face completed by the CRNP. There was no documentation that the patient was seen face to face by the narcotic treatment physician prior to initial dose. Inpatient record # 7 the face to face was completed by the CRNP on October 1, 2017. The patient was initially dosed on October 1, 2017. There was no documentation that the narcotic treatment physician signed off on the face to face completed by the CRNP. There was no documentation that the patient was seen face to face by the narcotic treatment physician prior to initial dose. These findings were reviewed with facility staff during the licening inspection.
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Plan of Correction
White Deer Run of York narcotic treatment physician will complete the face to face opiate dependency determination on all patients prior to administration of Buprenorphine.
Documentation of the face to face determination will be captured using an Opiate Dependency Checklist, which will be signed by the narcotic treatment physician.
White Deer Run of York Nursing Supervisor will audit a representative sample of records each month to ensure compliance.
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715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
The facility failed to document that the narcotic treatment physician determined the proper dosage level for a patient in six of seven patient records reviewed on April 24, 2018. The CRNP determined the doseage level for the patient in patient records # 1, 2, 4, 5, 6 and 7. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
White Deer Run of York narcotic treatment physician will determine the proper dosage level for each patient after completion of the face to face opiate dependency determination and prior to administration of Buprenorphine. The narcotic treatment physician will also determine dose changes for patients.
White Deer Run of York Nursing Supervisor will audit a representative sample of records each month to ensure compliance.
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