INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 2, 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 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility ' s fire drills logs from April 2023 through January 2024, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. The facility conducted a fire drill during sleeping hours in April 2023 and then again nine months later in January 2024.
This is a repeat citation from the March 10, 2023 licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility will ensure fire drills will be completed during sleeping hours at least every 6 months.
Director will meet with the Behavior Health Associates and go over the procedure for having at least 1 overnight fire drill per six months.
Ongoing: Director will review fire drill logs with BHA Supervisor quarterly. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility ' s fire drills logs from April 2023 through January 2024, 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, June, and August 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure that a fire alarm or smoke detector was set off for the fire drills. Director will meet with the Behavioral Health Associates and go over this procedure by 2/29/2024 during all staff meeting.
Fire drills will continue to be held monthly.
Ongoing Director and Behavioral Health Supervisor will monitor fire drill log monthly.. |
709.28 (c) 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.
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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 in one out of twelve records reviewed.
Client #12 was admitted to the detox level of care on June 17, 2023 and discharged on June 22, 2023 and was stepped down to the residential level of care on June 22, 2023 and was discharged on July 25, 2023. There was documentation that the facility contacted a medical provider; however, the facility did not have an informed and voluntary consent to release information signed by the client.
This finding was reviewed with 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.
Quality and Risk manager will conduct a training on the consents at the facility by March 22, 2024 where employees will be trained on the correct procedures for obtaining consent.
Clinical director and nurse manager will pull five random charts weekly over the next eight weeks to review and document consents are being completed correctly.
Since client #12 is no longer at the facility, we will not be able to obtain a release of information.
Ongoing, consents will be reviewed by Clinical Director, on monthly chart reviews and in supervisions.
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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 contained in the client record that included the specific information disclosed in one of twelve records.
Client #5 was admitted to the detox level of care on September 29, 2023 and discharged on October 5, 2023 and stepped down to the residential level of care on October 5, 2023 and discharged on November 1, 2023. An informed and voluntary consent from to a legal provider signed by the client on October 2, 2023 did not include the specific information to be disclosed.
This finding was reviewed with 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.
Quality and Risk manager will conduct a training on the consents at the facility by March 22, 2024 where employees will be trained on the correct procedures for obtaining consent.
Clinical director and nurse manager will pull 5 random charts weekly over the next eight weeks to review and document consents are being completed correctly.
Client is no longer in treatment to obtain a correct consent.
Ongoing, consents will be reviewed on monthly chart reviews and in supervisions top ensure we stay compliant.
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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.
Client #1 was admitted on January 30, 2024 and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information to the funding source and five informed and voluntary consents to release information to medical providers that were signed by the client on January 30, 2024, that had identified the purpose for disclosure as other, however no information was listed for what the other purpose was.
Client #3 was admitted on January 31, 2024 and was still active at the time of the inspection. The record contained four informed and voluntary consents to release information to medical providers that were signed by the client on January 31, 2024, that had identified the purpose for disclosure as other, however no information was listed for what the other purpose was.
Client #5 was admitted on September 29, 2023 and discharged on October 5, 2023. The record contained four informed and voluntary consents to release information to medical providers, two informed and voluntary consents to release information to the funding source, one informed and voluntary consent to release information to a legal provider, one informed and voluntary consent to release information to a drug and alcohol provider, and one informed and voluntary consent to release information to an emergency contact that were signed by the client on September 29, 2023 and an additional consent signed on October 2, 2023 for a legal provider that had identified the purpose for disclosure as other, however no information was listed for what the other purpose was.
Client #6 was admitted to the detox level of care on October 24, 2023 and discharged on October 29, 2023 and stepped down to the residential level of care on October 29, 2023 and discharged on November 28, 2023. The record contained two informed and voluntary consents to release information to the funding source, one informed and voluntary consent to release information to a medical provider, one informed and voluntary consent to release information to a legal provider and one informed and voluntary release of information to a drug and alcohol provider that were signed by the client on October 24, 2023 and a consent for a medical provider that was signed by the client on November 3, 2023. Each informed and voluntary consent had identified the purpose for disclosure as other, however no information was listed for what the other purpose was.
Client #7 was admitted to the detox level of care on March 19, 2023 and discharged on March 28, 2023. The record contained one informed and voluntary consent to release information form to a drug and alcohol facility that was signed by the client on March 27, 2023 that had identified the purpose for disclosure as other, however no information was listed for what the other purpose was.
Client #11 was admitted to the residential level of care on September 14, 2023 and discharged on October 18, 2023. The record contained two informed and voluntary consents to release information to the funding source, four informed and voluntary consents to release information to medical providers, one voluntary and informed consent to release information to a legal provider, and one voluntary and informed consent to release information to a mental health provider that were signed by the client on September 14, 2023, that had identified the purpose for disclosure as other, however no information was listed for what the other purpose was.
Client #12 was admitted to the residential level of care on June 17, 2023 and discharged on July 25, 2023. The record contained two informed and voluntary consents to release information to the funding source, four informed and voluntary consents to release information to medical providers, one informed and voluntary consent to release information to a mental health provider and one informed and voluntary consent to release information to the emergency contact that were signed by the client on June 17, 2023, that had identified the purpose for disclosure as other, however no information was listed for what the other purpose was.
These findings were reviewed with 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.
Quality and Risk manager will conduct a training on the consents at the facility by March 22, 2024 where employees will be trained on the correct procedures for obtaining consent.
Clinical director and nurse manager will pull 5 random charts weekly over the next eight weeks to review and document consents are being completed correctly.
The clients that are no longer in treatment will not receive a corrected consent, if the client is still active the client will be offered to sign a corrected release.
Ongoing, consents will be reviewed on monthly chart reviews and supervisions.
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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), qualifications for clinical staff, individual personnel training information, individual work performances, data collection form and the information related to clinical staff and the hours dedicated to detox patients were not presented timely or completed as required.
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 prior to the inspection.
Quality/Risk Manager has received technical support training on 2/28/2024 on the pre-submission process.
Quality/Risk Manager along with Human Resources will provide training to all leadership on proper completion of staffing grids as well as submission of documentation by 3/29/2024.
Ongoing: Quality/Risk Manager and Human Resources will review and ensure staffing grids and required documentation is submitted for inspections.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) 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 two applicable discharged records reviewed.
Client #4 was admitted to the detox level of care on December 1, 2023 and administratively discharged on December 4, 2023. A follow up was due per the facility ' s policy and procedure manual at thirty days after discharge; however, there is no documentation that one occurred.
Client #7 was admitted to the detox level of care on March 19, 2023 and discharged on March 28, 2023. A follow up was due per the facility ' s policy and procedure manual at thirty days after discharge; however, there is no documentation that one occurred.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will complete follow up information on every client. Director will review with all staff the procedure for completing the follow up and uploading the form in the medical record in the all staff meeting on 2/29/24.
Clinical Director will review 5 random charts weekly over the next eight weeks to ensure follow ups are being completed and placed in chart. Facility will go back and try to complete follow ups on the clients identified.
Ongoing, follow ups will be reviewed on monthly chart reviews and supervisions. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the facility ' s policy and procedures manual of every 14 days in four out of six records reviewed.
Client #6 was admitted on October 29, 2023 and discharged on November 28, 2023. A treatment plan was completed on November 1, 2023, and the next update was due no later than November 15, 2023; however, it was not completed until December 6, 2023.
Client # 9 was admitted on December 21, 2023 and still active at the time of the inspection. A treatment plan was completed on January 3, 2024, and the next update was due no later than January 17, 2024; however, it was not completed until January 24, 2024.
Client #11 was admitted on September 20, 2023 and discharged on October 18, 2023. A treatment plan was completed on September 21, 2023, and the next update was due on October 6, 2023; however, it was not completed until October 17, 2023.
Client # 12 was admitted on June 22, 2023 and discharged on July 25, 2023. A treatment plan was completed on June 23, 2023, and the next update was due no later than July 7, 2023; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure treatment plan updates are completed every 14 days. Clinical Director will provide a training to the counselors by March 22, 2024 reviewing the policy on treatment plan updates.
For the next eight weeks Clinical Director will pull 5 random charts and review for treatment plan updates. Due to the length of time, client charts identified cannot be corrected now.
Ongoing Clinical Director will review treatment plan updates during supervision and monthly chart audits. |