INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 25, 2008 through August 26, 2008 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 September 29, 2008.
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Plan of Correction
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records on August 25, 2008 through August 26, 2008, the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment.
Findings:
Based on a review of twelve client records, one record was required to have a notification of termination. The notification of termination was missing in one of one client record where required, # 6.
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Plan of Correction
Clinical Supervisor will retrain staff to verify that any patient who leaves the facility involuntarily completes a Notification of Termination of Treatment letter. If the staff member does not complete the letter, documentation must support this action by the Supervisor. The Notification of Termination of Treatment template letter will be included in the preparation of all new patient charts. Clinical staff will be retrained to use the Termination of Treatment Notification when appropriate, or to remove it from the chart if not required. Monthly chart auditing will monitor the compliance of the process. The clinical supervisor will complete the monthly chart audits and identify areas of improvement and corrective action plans for those not completing the form. |
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
Based on a review of facility fire drill records on August 25, 2008 through August 26, 2008, the facility failed to conduct a fire drill during sleeping hours at least every six months.
Findings:
Based on a review of facility fire drill records, the last fire drill conducted during sleeping hours occurred on December 20, 2007. A conversation with facility staff on August 25, 2008, confirmed this to be true.
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Plan of Correction
A fire drill was conducted during sleeping hours on September 18, 2008 at 6:27am. Protocol has been created for the Safety Officer to schedule and conduct fire drills on a regularly scheduled basis which has been reviewied to insure compliance with licensing requirements. The Safety Officer will document and report the drills to the Facility Director. The Facility Director has added electronic reminders in his calendar to insure future drills are taking place and will not be missed. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on August 25, 2008 through August 26, 2008, the facility failed to document a psychosocial evaluation in five of five client records reviewed.
Findings:
The psychosocial evaluation completed by nursing staff was not an assessment of the client's past and present circumstances, but rather consisted of two to three sentences regarding the client's demographics in five of five client records reviewed, #8, 9, 10 , 11 and 12.
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Plan of Correction
The 'Nursing Assessment' and the 'Detoxification Only Clinical Assessment Addendum' are approved by the Department to serve as the Psychosocial evaluation for 'detox only' patients.
Nursing staff will be re-trained in documentation by the Allenwood Assistant Director of Nursing no later than 9/26/08, and by the facility Clinical Supervisor no later than 10/17/2008 to ensure that the aforementioned documents contain the following:
1. clinical impressions/objective opinions to be evaluative of the overall composite picture of the patient's problems/needs - the medical, physical, emotional, social and behavioral consequences of the patient's chemical dependency and how these negative factors may affect treatment
2. the patient's assets/ strengths, current support systems, current coping mechanisms and the patient's attitude toward treatment are documented in the Nursing Assessment
Ongoing compliance will be ensured by the Director of Quality & Nursing Services and the facility Clinical Director who will each conduct two chart audits per week for six weeks, beginning 10/6/08 and at random thereafter.
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709.63(a)(8) LICENSURE Follow-up Information
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:
(8) Follow-up information.
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Observations
Based on a review of the facility's policy and procedure manual and client records on August 25, 2008 through August 26, 2008, the facility failed to document follow-up information within the required time frame according to regulation and facility policy.
Findings:
Based on a review of five client records, two records were required to have follow-up information documented. Follow-up information was documented three weeks late in one of two client records reviewed, #12. Follow-up for client record #12 was due within 7 days of the client's discharge date, but was documented four weeks after the client's discharge.
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Plan of Correction
Facility policy states that within one week of a patient's scheduled aftercare appointment the primary counselor/nurse will call the provider to determine if the patient in fact attended the appointment and inquire to the status of the patient. This call is documented in the patient chart on the specific Follow Up form provided. No further action is then required. In a non-routine discharge, the primary counselor/nurse will attempt to contact the patient within 30 days after discharge to check on the patient and document in the former patient's record. There is no further follow up thereafter. Employee Improvement Plans will be developed for the non compliant clinical staff by the Clinical Supervisor/Facility Director, or in the case the Clinical Supervisor is non compliant, the Facility Director will develop, implement and follow up as appropriate. Staff have been re-trained on compliance with the policy on Follow Up and will continue to be trained as new hires are employed. Clinical Supervisor is the responsible staff member achieving and maintaining compliance. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of facility staff schedules and staff CPR/first aid certification cards on August 25, 2008 through August 26, 2008, the facility failed to ensure that at least one person trained in these skills is onsite during the project's hours of operation.
Findings:
Based on a review of staff schedules and staff CPR/first aid certification cards, the facility did not have any staff trained in these skills on duty from 4:00 PM through midnight on the following dates: August 4, 2008, August 5, 2008, August 6, 2008, August 8, 2008, and August 15, 2008.
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Plan of Correction
As of 9-8-08, CPR/1st Aid certification training was conducted to insure staff were appropriately trained on all shifts. Supervisors responsible for schedules were retrained and instructed to verify that all staff are trained prior to being placed on the schedule. Quarterly trainings are being developed to include all newly hired staff with the anticipated goal of having 100% of staff trained. During the timeframe where staff are awaiting training, there will be a minimum of one trained staff per shift. This process will be monitored by department managers and ultimately the facility director. |