INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10, 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide close supervision by a trained counselor or clinical supervisor for the first 6 months of employment.
Employee #8 was hired on June 13, 2022 and was still employed at the time of the inspection. She had no documentation of direct and close supervision.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility director will review 704.9(c) with the clinical supervisor so there is an understanding of supervision requirements.
The Quality Director has updated the Supervision Documentation form to include clear documentation of close supervision or direct observation (co-facilitated or in-person) and the context of each form of supervision (group, individual, screening, intake, staff meeting, treatment team, training and case review).
The Quality Director has distributed the new Supervision Documentation form to all clinical supervisors to be implemented asap.
HR will review employee records on a quarterly basis to ensure compliance with required supervision periods.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for facility directors.
Employee #2 was hired as a facility director on February 3, 2019 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2022 through December 31, 2022. Employee # 2's record only document 10:48 hours of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility will assign a staff member to monitor training hours on site. The new Training Coordinator will keep track of all trainings completed by staff at the facility. A binder will be kept at the facility containing all training certificates with a tracker to monitor for hours.
The Training Coordinator will ensure all training certificates and evaluations are sent to the Quality Director. When staff are running low on training hours, the Quality Director will alert the staff's supervisor. The staff's supervisor will meet with the staff member and review training options to ensure compliance with 704.11(c)(3) & (4).
Quality Director will audit training hours on a quarterly basis to ensure compliance. Quality Director will send compliance reports to the Regional Program Director.
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling rooms.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The assistant facility director has covered the cameras that were operating in the group counseling rooms so sessions cannot be seen outside of the counseling room. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to provide either individual paper towels or a mechanical dryer in each client's bathroom.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility is contracted with a cleaning company to ensure each bathroom provides paper towels.
Facility bathrooms will be checked by staff on a daily basis for compliance.
Facility walk-throughs will be conducted at least once per shift, one time per month to monitor safety and compliance. Facility walk-through sheets will be submitted to the Quality Director on a quarterly basis to monitor for compliance.
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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 fire drill logs from March, 2022 through February, 2023 the facility failed to conduct a fire drill during sleeping hours at least every 6 months. A fire drill during sleeping hours was completed on June 26, 2022 and was due no later than December, 2022. As of the time of the inspection, it was not yet completed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility safety officer will coordinate a sleeping fire drill at a minimum of every six months. The facility safety officer will review and monitor fire drill log on a monthly basis.
The safety officer will send fire drill reports to the Quality Director on a quarterly basis. Quality Director will monitor for compliance.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of facility records, the facility failed to inform the Department of unusual incidents within the required three days. It was discovered that the facility had unusual incidents occur on August 26, 2022, September 19, 2022, September 28, October 7, 2022, and October 8, 2022 all of which involved presence of police, fire or ambulance personnel. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Unusual Incident reporting will be completed by the nurse manager or clinical supervisor per 709.34 (c)(4) regulation. Regional Nurse Manager and Quality Director will monitor reporting vs. the facility incident reports on a monthly basis for compliance.
The unusual incidents that were not entered, resulting in a citation, will be entered within the next 30 days. The dates of the incidents are as follows:
8/26/22, 9/19/22, 9/28/22, 10/7/22, 10/8/22
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709.14(b)(4) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(4) Change in activity/discontinuance of an activity.
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Observations
Based on a physical plant inspection, client record review and staff interviews, the facility is conducting narcotic treatment services utilizing buprenorphine without applying for and receiving the Department's approval. Per staff report, Buprenorphine treatment was first utilized starting in January, 2021.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility will apply and complete the application process to add the NTP activity to the current license to receive approval to utilize buprenorphine for narcotic treatment. |