INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on September 30, 2009 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 4 PA Code and 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on November 4, 2009.
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Plan of Correction
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715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of patient records, the facility failed to ensure a psychosocial evaluation was completed for 2 of 4 patient records.
The findings include:
Five patient records were reviewed on September 30, 2009. Four patient records were required to include documentation of a psychosocial evaluation. Patient records #1 and #3 did not include documentation of a psychosocial evaluation.
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Plan of Correction
Nursing staff is required to complete the psychosocial evaluation. The Regional Administrator and facility Nursing Supervisor will conduct training with all facility nursing staff on how to complete the Psychosocial as a component of the overall nursing assessment. The Nurse Manager will also conduct random chart audits each week on an on-going basis to ensure that procedures for completing the psychosocial are being followed by the nursing staff. We will also include more emphasis on completing the nursing assessment and psychosocial into our new hire orientation training for new nurses hired to work at the facility. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on the review of patient records, the facility failed to complete follow-up information for 3 of 4 patient records reviewed.
The findings include:
Five patient records were reviewed on September 30, 2009. Four patient records were required to include documentation of follow-up attempts. Patient records # 1, 3 and 4 did not include documentation of follow-up attempts.
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Plan of Correction
The facility had completed all five follow-up patient records and has a staff person assigned to do all client follow-up. However, during the review three files were not in the client record but were located in the "to be filed" folder which was not reviewed by the surveyor. While the follow-up records were completed they were not placed into the client record in a timely manner. The Regional Administrator will meet with the staff responsible for conducting follow-ups and for auditing client charts to review the procedure for timely filing of follow-up records. The Clinical Director and Nurse Manager will also conduct random file audits weekly on an on-going basis to ensure follow up records are included in the client chart in a timely manner. |
715.23(e) LICENSURE Patient records
(e) Patient file records, information and documentation shall be legible, accurate, complete, written in English and maintained on standardized forms or electronically.
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Observations
Based on the review of patient records and discussion with facility staff, the facility did not ensure the medical documentation was legible.
The findings include:
Five patient records were reviewed on September 30, 2009. Five patient records required legible, accurate, complete documentation. The physician's notes and the history and physicals completed by the physician were not legible. In discussion with the facility director, it was determined this had been addressed with the physician in the past, but there had been no change.
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Plan of Correction
The Regional Administrator has again meet with the Medical Director to discuss his illegible handwriting and concern with patient care as the result of staff being unable to read his instructions. The Medical Director has agreed to print his orders and medical instructions from this point forward and to improve the legibility of his handwriting. The Regional Administrator will monitor this issue and ensure the Medical Director follows through in improving his documentation. |