INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 12, 2021 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 the review of one applicable personnel record, the project failed to ensure that a counselor assistant with a high school diploma or GED equivalent counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first three months of employment and under close supervision for the following nine months.
Employee #7 was hired as a counselor assistant on November 2, 2020 and was supposed to only counsel clients under direct observation until February 2, 2021 and only under close supervision (one hour of direct observation and one hours of case review per week) for the following nine months; however, there was no documentation in the personnel record of direct observation or close supervision at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Clinical Supervisor will ensure Counselor Assistants with a Master's Degree will only counsel clients under documented, close supervision for at least the first three-months of employment by a trained counselor or Clinical Supervisor.
The Clinical Supervisor will ensure Counselor Assistants with a Bachelor's Degree will only counsel clients under documented, close supervision for at least the first six-months of employment by a trained counselor or Clinical Supervisor.
The Clinical Supervisor will ensure Counselor Assistants with an Associate's Degree will only counsel clients under documented, close supervision for at least the first nine-months of employment by a trained counselor or Clinical Supervisor.
The Clinical Supervisor will ensure Counselor Assistants with a High School Diploma will only counsel clients under documented, direct observation for the first three-months of employment, followed by documented, close supervision for the remaining nine-months of employment.
Employee #7 will receive documented, close supervision for the remaining eight-months of employment.
HR Director and Quality Director will monitor for compliance on a quarterly basis.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the review of fire drills conducted from February 2020 through February 2021, the facility failed to conduct unannounced monthly fire drills for the months of September 2020, December 2020, January 2021 and February 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility Safety Officer, under the supervision of the Risk Manager, will conduct unannounced fire drills at least once a month.
Risk Manager will monitor for compliance on a quarterly basis.
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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 the review of fire drills conducted from February 2020 through February 2021, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility Safety Officer, under the supervision of the Risk Manager, will conduct a fire drill during sleeping hours at least every six months.
Risk Manager will monitor for compliance on a quarterly basis.
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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included documentation of the specific information to be disclosed in two of seven client records reviewed.
Client #2 was admitted on January 10, 2021 and was a current client at the time of the inspection. Four release of information forms, one to a recovery hours, one to a state probation agency, one to a county probation agency and one to another treatment facility, signed and dated by the client on January 10, 2021, did not document the specific information to be disclosed.
Client #6 was admitted on September 10, 2020 and was discharged on October 5, 2020. A release of information form to the funding source, signed and dated by the client on October 2, 2020, did not document the specific information to be disclosed. Additionally, a release of information form to another facility, signed and dated by the client on September 10, 2020, did not document the specific information to be disclosed.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
All staff responsible for completing consents (nursing, clinical, admissions and intake staff) will attend the DDAP Confidentiality training by June 1, 2021. Certificate of attendance will be maintained in each training file.
Quality Director will hold an in-service training to be attended by staff responsible for completing consents (nursing, clinical, admissions and intake staff) at least once per month on confidentiality and proper completion of consents beginning April 1, 2021.
Monthly chart audits will be completed by nursing, clinical, admissions and intake staff to monitor for compliance. Results of monthly chart audits will be shared with Facility Director and Quality Director.
Consents for Client #2 and 6 cannot be obtained due to clients have discharged.
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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included documentation of the purpose of disclosure in two of seven client records reviewed.
Client #2 was admitted on January 10, 2021 and was a current client at the time of the inspection. Two release of information forms, one to a state probation agency and the other to another treatment facility, signed and dated by the client on January 10, 2021, did not document the purpose of disclosure.
Client #6 was admitted on September 10, 2020 and was discharged on October 5, 2020. A release of information form to another facility, signed and dated by the client on September 10, 2020, did not document the purpose of disclosure.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
All staff responsible for completing consents (nursing, clinical, admissions and intake staff) will attend the DDAP Confidentiality training by June 1, 2021. Certificate of attendance will be maintained in each training file.
Quality Director will hold an in-service training to be attended by staff responsible for completing consents (nursing, clinical, admissions and intake staff) at least once per month on confidentiality and proper completion of consents beginning April 1, 2021.
Monthly chart audits will be completed by nursing, clinical, admissions and intake staff to monitor for compliance. Results of monthly chart audits will be shared with Facility Director and Quality Director.
Consents for Client #2 and 6 cannot be obtained due to clients have discharged.
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