INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on August 31, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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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, the facility failed to document a psychosocial evaluation in client records #2, 3, 4, 5, and 7 as of the date of the licensing inspection.
Client #2 was admitted on August 26, 2020 and was still an active client at the time of the inspection.
Client #3 was admitted on August 26, 2020 and was still an active client at the time of the inspection.
Client #4 was admitted on August 26, 2020 and was still an active client at the time of the inspection.
Client #5 was admitted on August 1, 2020 and was discharged on August 3, 2020.
Client #7 was admitted on July 30, 2020 and was discharged on August 4, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical staff will be designated to complete the nursing addendum within 24 hours of admission, which will be serve as the psychosocial evaluation.
The clinical supervisor will be reviewing records on a daily basis to ensure compliance.
Random chart reviews will be conducted on a monthly basis to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director. Follow up and further training will be conducted with responsible staff should a record be out of compliance with 709.62 (c)(vi).
All of the records that were reviewed during the facility onsite inspection cannot be corrected due to the patients have already discharged.
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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, the facility failed to complete and document a discharge summary for client records #6 and #7.
Client #6 was admitted on July 29, 2020 and was discharged on August 3, 2020.
Client #7 was admitted on July 30, 2020 and was discharged on August 4, 2020.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Nursing and Clinical staff will be retrained on completing a Discharge Summary Training will be held on October 12th. Evidence of attendance will be maintained in the facility training files.
Random chart reviews will be conducted on a monthly basis to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director. Follow up and further training will be conducted with responsible staff should a record be out of compliance with 709.63 (a)(7).
Client records that were reviewed during the onsite facility inspection have been corrected to include discharge summaries in each client record.
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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 client records, the facility failed to complete and document a follow up for client records #5, #6 and #7.
Client #5 was admitted on August 1, 2020 an was discharged on August 3, 2020.
Client #6 was admitted on July 29, 2020 and was discharged on August 3, 2020.
Client #7 was admitted on July 30, 2020 and was discharged on August 4, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical and Case Management staff will be retrained on completion and documentation of follow up for each client record. Training will be held on October 12th. Evidence of attendance will be maintained in the facility training files.
Random chart reviews will be conducted on a monthly basis to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director. Follow up and further training will be conducted with responsible staff should a record be out of compliance with 709.63 (a)(8).
Client records that were reviewed during the onsite facility inspection have been corrected to reflect a completed follow up in each record.
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