INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensure inspection that was conducted on April 6 & 7, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from 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 supervisory review:
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based upon a review of the Staff listed on the Staffing Requirements Facility Summary Report form (SRFSR) completed by the facilty, the facility failed to list all staff that were working at the facility.
The SRFSR listed individuals serving as primary care staff for the detoxification unit that were not listed as facility employees or contracted staff anywhere else on the SRFSR clinical staff, other employees any where else on the SRFSR form.
Following the review of an additional document identifying agency nursing staff, it was determined that two individuals serving as primary care staff for the detoxification unit were not listed on the newly submitted document.
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Plan of Correction
Upon review of the submitted staffing roster, it appears that one agency staff person was not included on the roster, although credentials were included in the packet for this staff person. The facility will submit an updated roster to include this individual's name, position and date of hire (date first worked in the facility). All future rosters will include agency staff used on the initial submission. |
704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based upon a review of the Staff listed on the Staffing Requirements Facility Summary Report form (SRFSR) completed by the facilty, the facility was not able to verify that one primary care staff for every seven clients.
The SRFSR listed individuals serving as primary care staff for the detoxification unit that were not listed as facility employees or contracted staff anywhere else on the SRFSR clinical staff, other employees any where else on the SRFSR form.
Following the review of an additional document identifying agency nursing staff, it was determined that two individuals serving as primary care staff for the detoxification unit were not listed on the newly submitted document.
Individual #1 was on the schedule as the third of three required staff working in the detox unit from 7:00AM - 7:00 PM on Sunday at the beginning of the week and Friday and Saturday at the end of the week for 20 clients on Sunday 21 clients on Friday and 19 clients on Saturday.
Individual #2 was on the schedule as the second of three required staff working in the detox unit from 7:00AM - 7:00 PM on Saturday at the end of the week for 19 clients
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Plan of Correction
Upon review of the submitted staff schedule for the detoxification activity, it appears that the facility failed to include the full name of individual #2 and individual #1 was not listed on the staffing roster. The facility will update the schedule to include full names of all staff and will also submit the updated roster to include the name of individual #1 as an agency staff person working on that date. All future submissions of staff rosters will include full names of agency staff working as primary care and these staff will also be included on the staff roster. |