INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on January 23, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, 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.
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Plan of Correction
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide individual counseling, at least twice weekly in 3 of 5 records reviewed. Client # 2 was admitted September 21, 2023, and discharged October 19, 2023. Only one individual counseling session was documented for the weeks of 9/24/23 and 10/1/23. Client # 3 was admitted September 21, 2023, and discharged October 25, 2023. Only one individual counseling session was documented for the week of 9/24/23. No individual counseling sessions were documented the weeks of 10/8/23 or 10/15/23.Client # 5 was admitted November 13, 2023, and discharged November 28, 2023. Documentation of individual counseling sessions was missing from this chart.
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Plan of Correction
Plan of Correction:
Two individual counseling sessions will be provided on a weekly basis.
Individual counseling sessions are scheduled on a calendar in the clinician's office, supervisor's office and posted in the PHP Sign In book.
Each counselor will provide their assigned client with a scheduled of their individual counseling sessions. In addition, each counselor will provide Program Director with a schedule of all clients' scheduled individual sessions. In addition, all individual counseling sessions will be posted and updated monthly.
When client does not show for his/her individual counseling session and the assigned counselor will write a case note to reflect the no show. In addition, the assigned counselor, will document this on the clients Record of Service.
Random. Monthly chart audits will be conducted by a quality committee with a least member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
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709.83(a)(2) LICENSURE Client records
709.83. 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:
(2) Treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to provide a complete client record which is to include the treatment and rehabilitation plan in 2 of 5 records reviewed.. Per the facility's Treatment Planning policy, the treatment care plan is to be completed within seven days of admission.Client # 3 was admitted September 21, 2023, and discharged October 25, 2023. Documentation of a treatment care plan was missing from this client record.Client # 5 was admitted November 13, 2023, and discharged November 28, 2023. Documentation of a treatment care plan was missing from this client record.
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Plan of Correction
Plan of Correction:
Per White Deer Run Policy, all clients will complete a record which includes information that is relevant to his/her involvement in treatment. Among demographics, diagnoses, and problem concerns, a preliminary individual treatment and rehabilitation plan will be provided in a seven-day period from the time of admission. This is completed for all incoming clients. Master treatment plans will be created and active within 30 days after their preliminary treatment plan at admission. Program Manager and Lead counselor will review all incoming clients at the end of each week for a period of 60 days. Additionally, random monthly chart audits will be conducted by The Director and Risk and Compliance manager to monitor for corrections and as needed additional supervision. Results of the audit will be submitted on a monthly basis to Risk and Compliance. Implementation is effective immediately and to ensure continued compliance, random monitoring of all charts will be completed ongoing without notice every other month.
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