INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, White Deer Run of York Assessment Center 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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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on the review of the facility ' s fire drill logs from April 2023 through December 2023, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill for the months of April to December 2023
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Due to this building being historic property. The Facility Director will be the designated person to set off the smoke detectors. In addition, the Facility Director will contact the landlord of this building to contact the City of York on how to seek a fire drill exception. In the meantime, fire drills will be conducted monthly during all shifts and documented in the fire drill manual. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary release of information to include specific information to be disclosed in two out of seven records reviewed.
Client #6 was admitted on May 19, 2023 and discharged on May 19, 2023. The record contained one informed and voluntary consent to release information to the funding source signed by the client on May 19, 2023, that did not include the specific information to be disclosed.
Client #7 was admitted on September 25, 2023 and discharged on September 25, 2023. The record contained one informed and voluntary consent to release information to a legal entity and one informed and voluntary consent to release information for an emergency contact signed by the client on September 25, 2023, that did not include the specific information to be disclosed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility will obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. This will include specific information to be disclosed.
Corporate Compliance will conduct a training on the consents for the facility by April 5 where employees will be trained on the correct procedures for obtaining consent.
Clinical Director will pull five random charts weekly over the next eight weeks to review and document consents are being completed correctly.
Since client 6 was discharged no further action can be completed with their consents.
Ongoing: consents will be reviewed by Clinical Director and Compliance on monthly chart reviews and in supervisions.
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709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one out of seven records reviewed.
Client #7 was admitted on September 25, 2023 and discharged on September 25, 2023. The record contained one informed and voluntary consent to release information to a legal provider and one informed and voluntary consent to release information for an emergency contact signed by the client on September 25, 2023, that did not have the purpose for disclosure documented.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility will obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. This will include purpose of disclosure documented.
Corporate Compliance will conduct a training on the consents for the facility by April 5 where employees will be trained on the correct procedures for obtaining consent.
Clinical Director will pull five random charts weekly over the next eight weeks to review and document consents are being completed correctly.
Since client 7 was discharged and no additional consents can be completed at this time.
Ongoing: consents will be reviewed by Clinical Director and Compliance Officer on monthly chart reviews and in supervisions. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of seven client records reviewed.
Client #4 was admitted on April 17, 2023 and discharged on April 17, 2023. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated April 17, 2023 was offered to the client.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility will obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. Specifically, an informed consent will be obtained, and documentation will include that a copy of the release was offered to the client.
Corporate Compliance will conduct a training on the consents for the facility by April 5 where employees will be trained on the correct procedures for obtaining consent.
Clinical Director will pull five random charts weekly over the next eight weeks to review and document consents are being completed correctly.
Since client 4 was discharged no further documentation can be obtained at this time.
Ongoing: consents will be reviewed by Clinical Director and Compliance on monthly chart reviews and in supervisions. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of administrative information, client records, personnel records, and the facility policy manual, the facility failed to develop a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
The following materials were requested however the facility was unable to provide them during the licensing process:
The Staffing Requirement Facility Summary Report (SRFSR), client records, training documentation, individual work performances, and CPR cards.
This finding was reviewed with the facility during the licensing process.
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Plan of Correction
The facility will complete pre-submission documentation including staffing summary report, training plans, work performances and data collection form prior to the inspection.
Risk /Quality Manager has received technical support training on 2/28/24 on the pre=submission process
Risk and quality manager along with HR will provide training to all leadership on the proper completion of staffing grids as well as submission of documentation by 3/29/24.
HR and Risk/Quality management will review staffing requirement summary report prior to submitting to DDAP
Ongoing: Monthly HR and Risk will review personal records and update for new hires
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709.42(b)(2) LICENSURE Preliminary Treatment Plan
709.42. Project management.
(b) The intake project or treatment service providers shall have a written procedure for the performance of the following functions:
(2) Preparation of a preliminary treatment plan utilizing appropriate available service resources and listing the services to be provided. This plan shall be developed in cooperation with and agreed to by the intake project or treatment service provider and the client. The service plan shall also include referral to services not specifically for drug and alcohol clients; for example, legal services and dental services for which the client may be eligible.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to have a written procedure for the performance of the preparation of a preliminary treatment plan utilizing appropriate available service resources and listing the services to be provided. This plan shall be developed in cooperation with and agreed to by the intake project or treatment service provider and the client. The service plan shall also include referral to services not specifically for drug and alcohol clients; for example, legal services and dental services for which the client may be eligible.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will develop a written procedure for the performance of a preliminary treatment plan.
Plan of Correction:
The facility Program manager and Region Director will develop procedures around the completion of a preliminary treatment plan that will be completed with the input of the client.
These policies and procedures will be developed by April 15, 2024, with training on the new procedures to be facilitated immediately following with staff.
Once approved the Regional Vice President or designee will monitor completion and/or compliance of protocol and training on an ongoing basis.
Staff will be educated and trained on the use and application of the preliminary treatment plan and how to implement referral services into the plan as discussed collaboratively with the client. Training with direct line staff will be completed upon approval of new protocol and policies but no later than April 22nd, 2024.
QI manager and Facility Program Manager will monitor for compliance by random chart reviews weekly over the next 60 days.
Ongoing monthly chart review monitors will continue with the QI manager and facility manager
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709.44(a)(3) LICENSURE Psychosocial evaluation
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(3) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in six out of seven applicable records.
Client #1 was admitted on June 7, 2023 and discharged on June 7, 2023. There is no documentation that a psychosocial evaluation was completed.
Client #2 was admitted on December 8, 2023 and discharged on December 8, 2023. There is no documentation that a psychosocial evaluation was completed.
Client #3 was admitted on November 22, 2023 and discharged on November 22, 2023. There is no documentation that a psychosocial evaluation was completed.
Client #5 was admitted on July 12, 2023 and discharged on July 12, 2023. There is no documentation that a psychosocial evaluation was completed.
Client #6 was admitted on May 19, 2023 and discharged on May 19, 2023. There is no documentation that a psychosocial evaluation was completed.
Client #7 was admitted on September 25, 2023 and discharged on September 25, 2023. There is no documentation that a psychosocial evaluation was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility program manager and Region Director will implement a psychosocial evaluative practice and procedure by April 5, 2024, with training for the direct line staff on the protocol to occur by April 5th, 2024.
Facility will document a complete psychosocial evaluation at time of assessment, which will be stored in the client record.
This will be in all charts moving forward. Since client 1,2,3,4,5,6 are no longer at the facility this will not be corrected in their charts.
This procedure will be monitored weekly over the next 60 days by facility manager and quality risk manager.
Ongoing random record reviews will be completed monthly by facility manager for compliance.
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