INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 17-18th 2019 of White Deer Run of York by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
Based on a review of the project's policy and procedure manual, position descriptions, and an interview with facility staff, the project failed to ensure that the staff persons meet the educational and experiential qualification requirements of chapter 704.
The position description for the Director of Program Management, also known as the Facility Director, does not include the requirement that the person have experience in program planning.
The facility staff stated that their Counselor 2 position, was the equivalent of a counselor as per the Department of Drug and Alcohol Programs staffing regulations. However, the position description for a Counselor 2, only requires a high school diploma, and not an Associate degree or higher.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR department ensure the need for experience in program planning as a qualification for the Facility Director role will be added to the system's job description.
The line stating that a high school diploma is acceptable for a Counselor level position will be removed from the Counselor 2 job description by the HR manager. A line stating the education requirement for a counselor is a minimum of an associate's degree in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in human services) or other related field will be added by the HR manager.
The executive director's designee will review the project's policies and procedures against DDAP regulations annually to ensure compliance.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #8, #9 and #10 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #8 was hired as a Cook on Septebmer 13, 2016 and was due to have the communicable disease trainings no later than September 13, 2018. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #9 was hired as a Clinical Tech on January 30, 2017 and was due to have communicable disease training no later than January 30, 2019. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #10 was hired as a Clinical Tech on March 21, 2017 and was due to have communicable disease training no later than March 21, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility Director and department managers will ensure employees receive a minimum of 6 hours of HIV/AID training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe. Upon completion of required trainings, employees will submit certificates of training to the Quality Improvement Manager for employee training files. Compliance will be monitored through record reviews by the Quality Improvement Manager and HR Department on a monthly basis. Results of record reviews will be shared with the Facility Director and department managers. Employee #8 completed TB/STD training on 3/12/19 and HIV/AIDS on 3/11/19. Employee #9 completed TB/STD training on 9/11/18 and HIV/AIDS on 9/20/18. Employee #10 completed TB/STD training on 1/25/18 and HIV/AIDS on 3/20/19. All training certificates have been placed in the employee personnel training files. The executive director's designee will review employee trainings regularly along with the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy or procedure for utilization of volunteers.
These findings were reviewed with facility during the licensing inspection.
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Plan of Correction
The executive director will create a policy in relation to volunteers for the system.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of the project's policy and procedure manual, the project's confidentiality policy does not include 4 Pa. 255.5(a)(6) identifying the limitation of information that may be disclosed to employers or prospective employers of the client. In addition, project's policy and procedure manual does not identify the person responsible for maintaining electronic records.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will revise the confidentiality policy so it includes the limitation of information that may be disclosed to employers of the client.
The executive director will revise the confidentiality policy to include identification of the person responsible for maintaining electronic records.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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709.28 (a) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
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Observations
Based on a review of the project's policy and procedure manual, the project's procedures do not address the methods by which staff gain access to electronic records.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will revise the confidentiality policy so it addresses the methods by which staff gain access to medical records.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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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 sevehn client records, the facility failed to document a completed consent to release information in 1 records, as there were forms that were missing required information.
Client #6 was admitted on October 18, 2018 and was discharged November 15, 2018. There was consent to release forms, signed and dated on October 18, 2018 to external providers, hospitals, a pharmacy, funding source and county agency but the consent form did not include what information could be released.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Quality Improvement Manager will conduct a mandatory Confidentiality/Consent Training to all nursing and admission staff. Evidence of attendance will be maintained in the facility training files.
Chart reviews will be conducted on a monthly basis by the Chart to Charge Committee to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director.
Consents cannot be obtained on Client #6 because the client has been discharged from treatment.
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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 sevehn client records, the facility failed to document a completed consent to release information in 1 records, as there were forms that were missing required information.
Client #6 was admitted on October 18, 2018 and was discharged November 15, 2018. There was consent to release forms, signed and dated on October 18, 2018 to external providers, hospitals, a pharmacy, funding source and county agency but the consent form did not include the purpose of disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Quality Improvement Manager will conduct a mandatory Confidentiality/Consent Training to all nursing and admission staff. Evidence of attendance will be maintained in the facility training files.
Chart reviews will be conducted on a monthly basis by the Chart to Charge Committee to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director.
Consents cannot be obtained on Client #6 because the client has been discharged from treatment.
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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 the review of sevehn client records, the facility failed to document a completed consent to release information in 1 records, as there were forms that were missing required information.
Client #7 was admitted on October 10, 2018 and was discharged October 28, 2018. There was consent to release forms, signed and dated on October 26, 2018 to Probation Officer, did not include the signature and date of witness.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Quality Improvement Manager will conduct a mandatory Confidentiality/Consent Training to all nursing and admission staff. Evidence of attendance will be maintained in the facility training files.
Chart reviews will be conducted on a monthly basis by the Chart to Charge Committee to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director.
Consents cannot be obtained on Client #7 because the client has been discharged from treatment.
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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 the review of sevehn client records, the facility failed to document a completed consent to release information in 1 records, as there were forms that were missing required information.
Client #6 was admitted on October 18, 2018 and was discharged November 15, 2018. There was consent to release forms, signed and dated on October 18, 2018 to external providers, hospitals, a pharmacy, funding source and county agency but the consent form failed to document if the client was offered a copy of the consent.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Quality Improvement Manager will conduct a mandatory Confidentiality/Consent Training to all nursing and admission staff. Evidence of attendance will be maintained in the facility training files.
Chart reviews will be conducted on a monthly basis by the Chart to Charge Committee to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director.
Consents cannot be obtained on Client #6 because the client has been discharged from treatment.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the project's policy and procedure manual, the project failed to include in its policies that that the project may not discriminate in the provision of services based on age, ethnicity, marital status and/or creed.
The Intake and Admission Continuum of Care Policy and Procedure for Intake and Admissions for Partial Hospital, Outpatient Part II and Adult Admission Criteria Part II, does not include age, ethnicity, and marital status for those who will not be discriminated against.
The Intake and Admission Continuum of Care Policy and Procedure for Intake and Admissions for the Intake, Evaluation and Referral Activity does not include age, ethnicity, and marital status for those who will not be discriminated against.
In the project's Rights Responsibilities and Ethics (RI), subject "Patients Rights" Policy and Procedure, Under Procedure: A. 1. "creed" is not included.
The signed client rights documentation in the client's record does not include creed for those who will not be discriminated against.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director will revise the patient rights so they include that the project may not discriminate in the provision of services based on age, ethnicity, marital status and/or creed.
The executive director will add "creed" to the Rights Responsibilities and Ethics subject "Patient Rights" policy and procedure A.1. section.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy or procedure for documentation of medication administration when self-administered by the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will revise the current policy that exists on medication administration and self-administration so it includes reference to the current self medication documentation form.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy relating to maintaining copies of drug-related regulations being available in appropriate areas.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will add a policy that addresses the need to maintain copies of drug-related regulations in appropriate areas to the regional policy and procedure manual.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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709.53(a) LICENSURE Complete Client Record
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:
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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 record of services, discharge summary, after care plan and follow up in client records #1, 4, 6 and 7.
Client #1 was admitted on March 24, 2019 and was still active at the time of inspection. The client record did not contain documentation of a completed record of service.
Client #4 was admitted on September 25, 2018 and was discharged October 23, 2018. The client record did not contain a completed record of service, discharge summary or follow up.
Client #6 was admitted on October 18, 2018 and was dicharged November 15th 2018. The client record did not contain a follow up.
Client #7 was admitted on October 10, 2018 and was discharged on October 31, 2018. The client record did not contain an aftercare plan or follow up.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical staff will update the Record of Service in real time after every encounter. Clinical Director will monitor client records.
Seven day post discharge Follow up contact will be completed by the Case Manager on a daily basis. Follow up documentation will be placed in the client record after each contact.
Continuing Care/After Care plans will be completed by the Case Manager and client prior to discharge. Continuing Care/After Care plans will be placed in the client record following discharge.
Multi-Disciplinary Discharge Summaries will be completed by clinical staff and placed in the client record no later than seven days post discharge.
Chart reviews will be conducted on a monthly basis by the Chart to Charge Committee and through Monthly Residential Chart Audits to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director.
The Record of Service has been updated on Client #1.
Post discharge follow up contact was attempted on client #4, but was unsuccessful. Documentation of follow up was filed in the client record. The Record of Service was updated. The Multi-Disciplinary Discharge Summary was completed and filed in the record.
Post discharge follow up contact was attempted on client #6, but was unsuccessful. Documentation of follow up was filed in the client record.
Post discharge follow up contact was attempted on client #7, but was unsuccessful. Documentation of follow up was filed in the client record. The Continuing Care/After Care plan is unable to be obtained because the client has been discharged.
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