INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 15, 2023 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 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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709.28 (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 a completed informed and voluntary consent which included specific information to be disclosed in one out of fourteen records reviewed.
Client # 9 was admitted on January 3, 2023 and was still active at that the time of the inspection. One release of information dated January 3, 2023 was to a funding source.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the March 25, 2022 licensing inspection.
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Plan of Correction
Upon hire, staff responsible for completing consents will receive one on one training with their supervisor on how to properly complete a consent. Competency assessment will be completed after the training.
All staff responsible for completing consents will be required to take DDAP Confidentiality training on PA Train within the first 90 days of hire. Training certificates will be maintained in employee training files.
Quality Director will conduct confidentiality training during all new employee orientation trainings, which will include training on how to complete a consent. New employee orientation will occur on a monthly basis, as needed.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
Client #9 is no longer in treatment and the consent cannot be obtained.
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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 a completed informed and voluntary consent which included purpose of disclosure in one out of fourteen records reviewed.
Client # 9 was admitted on January 3, 2023 and was still active at that the time of the inspection. One release of information dated January 3, 2023 was to a funding source. An additional release of information dated March 3, 2023 was to a medical provider.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon hire, staff responsible for completing consents will receive one on one training with their supervisor on how to properly complete a consent. Competency assessment will be completed after the training.
All staff responsible for completing consents will be required to take DDAP Confidentiality training on PA Train within the first 90 days of hire. Training certificates will be maintained in employee training files.
Quality Director will conduct confidentiality training during all new employee orientation trainings, which will include training on how to complete a consent. New employee orientation will occur on a monthly basis, as needed.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
Client #9 is no longer in treatment and the consent cannot be obtained.
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709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in four out of seven applicable records.
Client #8 was admitted on January 23, 2023 and was still active at the time of the inspection.
Client #9 was admitted on January 3, 2023 and was still active at the time of the inspection.
Client #10 was admitted on February 8, 2023 and was still active at the time of the inspection.
Client #14 was admitted on November 4, 2022 and was discharged on December 2, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon admission, each client will meet with a clinician to have a psychosocial evaluation completed per 709.81(b)(6).
The Clinical Director will review all new admissions on a weekly basis to ensure documentation of psychosocial evaluations.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
Psychosocial evaluations will be completed on all deficient records where the client is still in treatment.
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in one out of two applicable records reviewed.
Client #13 was admitted on October 12, 2022 and was discharged on January 5, 2023. A treatment plan was completed on October 27, 2022 and an update was due no later than November 27, 2022; however, none was completed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinician will complete a treatment plan update for every client in the treatment program at least every 30 days.
The Clinical Director will review active client records with Counselors during supervision to ensure treatment plan updates are completed and in a timely fashion.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
The treatment plan update for Client #13 cannot be completed because the client has already discharged.
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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 seven partial hospitalization client records, the facility failed to provide and document at least two individual counseling sessions per week for all client records reviewed.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from licensing inspection completed on March 25, 2022.
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Plan of Correction
Two individual counseling sessions will be provided to clients on a weekly basis.
Individual sessions are scheduled on a calendar in the clinician's office. Clients are informed of their next scheduled visit with the conclusion of each visit.
The Clinical Director will review active client records with counselors during supervision to ensure counseling sessions are occurring as required.
Random, monthly chart audits will be conducted by a quality committee with at least one 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)(6) 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:
(6) Aftercare plans, if applicable.
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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 an aftercare plan in one out of two applicable discharged records reviewed.
Client #13 was admitted on October 12, 2022 and was discharged on January 5, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The case manager or counselor will complete an aftercare plan with every client prior to discharge.
The Clinical Director will review closed client records with counselors during supervision to ensure aftercare plans are completed as required.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
The Aftercare Plan for Client #13 cannot be completed due to the client already discharged from treatment.
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709.83(a)(10) 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:
(10) Discharge summary.
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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 a discharge summary in two out of three discharged records reviewed.
Client #12 was admitted on December 7, 2022 and was discharged on December 23, 2022.
Client #13 was admitted on October 12, 2022 and was discharged on January 5, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinician will complete a discharge summary for each discharged client no later than 30 days post-discharge.
The Clinical Director will review closed client records with Counselors during supervision to ensure discharge summaries are completed as required.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
A Discharge Summary will be completed for Clients #12 and #13.
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709.83(a)(11) 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:
(11) Follow-up information.
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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 follow-up information in two out of three discharged records reviewed.
Client #12 was admitted on December 7, 2022 and was discharged on December 23, 2022.
Client #13 was admitted on October 12, 2022 and was discharged on January 5, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will complete a follow up for each discharged client.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
A Follow Up will be completed for Client #12 and #13.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed ensure that an individual treatment plan and rehabilitation plan shall be developed with the client in three out of seven records reviewed.
Client #4 was admitted on August 20, 2022 and was discharged on December 21, 2022. No treatment plan was completed.
Client #5 was admitted on October 21, 2022 and was discharged on December 21, 2022. No treatment plan was completed.
Client #6 was admitted on September 29, 2022 and was discharged on November 4, 2022. No treatment plan was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinician will complete an individual treatment & rehabilitation plan for every client.
The Clinical Director will review active client records with counselors during supervision to ensure treatment plans are completed as required.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
Treatment Plans cannot be completed on Clients #4, 5 and 6 due to clients have discharged.
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709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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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 an aftercare plan in one out of one applicable discharged records reviewed.
Client #7 was admitted on August 12, 2022 and was discharged on October 21, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The case manager or counselor will complete an aftercare plan with every client prior to discharge.
The Clinical Director will review closed client records with counselors during supervision to ensure aftercare plans are completed as required.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
The Aftercare Plan for Client #7 cannot be completed due to the client already discharged from treatment.
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709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
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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 follow-up information in four out of four discharged records reviewed.
Client #4 was admitted on August 20, 2022 and was discharged on December 21, 2022.
Client #5 was admitted on October 21, 2022 and was discharged on December 21, 2022.
Client #6 was admitted on September 29, 2022 and was discharged on November 4, 2022.
Client #7 was admitted on August 12, 2022 and was discharged on October 21, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will complete a follow up for each discharged client.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
A Follow Up will be completed for Client # 4, 5, 6 and 7 and placed in the client record.
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