INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25, 2022, 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 an informed and voluntary consent from the client for the disclosure of information in the client record that contained the specific information to be disclosed in one of the fourteen client records reviewed.
Client #8 was admitted on February 28, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information was signed and dated on March 23, 2022, to outside agencies that failed to document specific information to be disclosed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Quality Director will conduct Confidentiality/Consent training with employees responsible for completing consents (clinical, intake/admissions, case management). A sign in sheet will be completed and maintained for record.
Additionally, all staff responsible for completing consents will be required to take DDAP Confidentiality training on PA Train. 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 #8 consent was obtained.
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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 obtain an informed and voluntary consent from the client for the disclosure of information to include documentation that a copy of the consent was offered to the client in one of the fourteen records reviewed.
Client #8 was admitted on February 28, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information was signed and dated on March 23, 2022, to outside agencies that failed to include documentation that a copy of the consent was offered to the client.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Quality Director will conduct Confidentiality/Consent training with employees responsible for completing consents (clinical, intake/admissions, case management). A sign in sheet will be completed and maintained for record.
Additionally, all staff responsible for completing consents will be required to take DDAP Confidentiality training on PA Train. 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 #8 consent was obtained. The client was offered a copy and declined. |
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 client records, the facility failed to provide and document at least two individual counselling session per week for all client records reviewed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The counselor responsible for the PHP program will scheduled, hold, and document at least two individual sessions per week for each PHP client. Documentation of the individual sessions will be maintained in the client record.
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.
Program Director will also monitor for compliance on a weekly basis through random chart audits. |