INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of six personnel records, it was determined that one applicable counselor did not meet the qualification for the position at the time of hire.
Employee #4 was hired as a counselor June 1, 2021, with a bachelor ' s degree but did not have the required one year of clinical experience at the time of hire.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The HR Director and Facility Director will monitor each new hire for qualifications to ensure employees classified as a counselor will have at least one year of clinical experience (1,820 hours) in a health or human services agency, preferably in a drug and alcohol setting. In the event the employee's experience did not take place in a drug and alcohol setting, the employee's individual training plan will address a plan to achieve counseling competency for a drug and alcohol setting.
HR Director and Facility Director will monitor for compliance with each new clinical hire by reviewing education and experience.
Employee #4 will be placed into a counselor assistant position until they reach one year of clinical experience (1,820 hours) and achieve clinical competency for a drug and alcohol setting. This employee will receive weekly supervision until promoted to the position of counselor. The Clinical Supervisor will document and maintain evidence of supervision.
HR Director and Facility Director will monitor supervision logs to ensure compliance with the regulation.
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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 failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
A counseling session that was being conducted in counseling room 48 could be heard from outside of the room.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical staff shall ensure counseling sessions cannot be seen or heard outside the counseling room by placing a sound machine outside of all counseling offices and group rooms.
Clinical Supervisor will ensure Room 48 has a sound machine placed outside.
Random, monthly environmental rounds will be completed by the Facility Safety Officer to monitor for compliance. Environmental Rounds will be submitted to the Quality Director on a monthly basis.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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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 the name of the person, agency, or organization to whom disclosure is made in two of fourteen client records reviewed.
Client # 1 was admitted on March 21, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated March 21, 2022, did not provide the name of the person, agency or organization to whom the disclosure can be made.
Client #7 was admitted on October 5, 2021 and was discharged on October 10, 2021. An informed and voluntary consent from the client for the disclosure of information signed and dated on October 5, 2021, did not provide the name of the person, agency or organization to whom the disclosure can be made.
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 (nursing, 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 ,#1 #7 are no longer in treatment and a consent is unable to be obtained.
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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 to be released in three of fourteen client records reviewed.
Client #1 was admitted on March 21, 2022 and was still active at the time of inspection. An informed and voluntary consent from the client for the disclosure of information was signed and dated on March 21, 2022 that failed to document specific information to be released.
Client #7 was admitted on October 5, 2021 and was discharged on October 10, 2021. An informed and voluntary consent from the client for the disclosure of information was signed and dated on October 5, 2021 that failed to document specific information to be released.
Client #13 was admitted on November 22, 2021 and was discharged on December 21, 2021 An informed and voluntary consent from the client for the disclosure of information was signed and dated on November 22, 2021 to the emergency contact that failed to document specific information released.
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 (nursing, 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 #1, #7 and #13 are no longer in treatment and a consent is unable to 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 an informed and voluntary consent from the client for the disclosure of information contained in the client record that contained a purpose of disclosure in one of fourteen client records reviewed.
Client #7 was admitted on October 5, 2021 and was discharged on October 10, 2021. An informed and voluntary consent from the client for the disclosure of information was signed and dated on October 5, 2021, that failed to include the purpose of the disclosure.
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 (nursing, 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 , #7 is no longer in treatment and a consent is unable to be obtained.
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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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 contained a dated signature of a witness in two of fourteen client records reviewed.
Client #7 was admitted on October 5, 2021 and was discharged on October 10, 2021. An informed and voluntary consent from the client for the disclosure of information was signed and dated on October 5, 2021, that failed to include the dated signature of witness.
Client #10 was admitted on March 23, 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, for the emergency contact that failed to include the dated signature of witness.
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 (nursing, 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 #7 and #10 are no longer in treatment and a consent is unable to be 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 three of the fourteen client records reviewed.
Client #1 was admitted on March 21, 2022 and was still active at the time of inspection. An informed and voluntary consent from the client for the disclosure of information was signed and dated on March 21, 2022, that failed to include documentation that a copy of the consent was offered to the client.
Client #7 was admitted on October 5, 2021 and was discharged on October 10, 2021. An informed and voluntary consent from the client for the disclosure of information was signed and dated on October 5, 2021, that failed to include documentation that a copy of the consent was offered to the client.
Client #13 was admitted on November 22, 2021 and was discharged on December 21, 2021. An informed and voluntary consent from the client for the disclosure of information was signed and dated on November 22, 2021, for the emergency contact 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 (nursing, 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 #1 #7 and #13 are no longer in treatment and a consent is unable to be obtained.
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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 the facility ' s policy and procedure manual and seven client records, the facility failed to complete, and document follow up information in all three applicable client records reviewed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Facility Director will be retrain clinical staff on completion and documentation of follow up for each client record. Evidence of training will be maintained in the facility training files.
Random, monthly cart 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 records that were reviewed during the onsite facility inspection have been corrected to reflect a completed follow up in each record.
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709.53(a)(9) LICENSURE Aftercare plans
709.53. 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 seven client records, the facility failed to provide a complete client record, which is to include aftercare plans in two of the three applicable records reviewed.
Client #12 was admitted on November 29, 2021 and discharged on December 21, 2021. The client record failed to include an aftercare plan.
Client #13 was admitted on November 22, 2021 and was discharged on December 21, 2021. The client record failed to include an aftercare plan.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Clinical staff will ensure a Continuing Care/Aftercare Plan is completed with all clients prior to discharge. At discharge, the client will receive a copy of the Continuing Care/Aftercare Plan and a copy will be placed 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.
Client #12, and #13 had been discharged and all aftercare paperwork was sent with the client.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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 the facility ' s policy and procedure manual and seven client records, the facility failed to complete, and document follow up information in all three applicable client records reviewed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Facility Director will be retrain clinical staff on completion and documentation of follow up for each client record. Evidence of training will be maintained in the facility training files.
Random, monthly cart 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 records that were reviewed during the onsite facility inspection have been corrected to reflect a completed follow up in each record.
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