INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 4, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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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 ensure that all consent to release forms contained the specific information to be released in client records #1 and #6.
Client #1 was admitted on August 18, 2020 and was still active at the time of inspection. A consent to release form was signed and dated on August 21, 2020 to a county agency that failed to document specific information to be released.
Client #6 was admitted on May 2, 2020 and was discharged on July 10, 2020. A consent to release form was signed and dated on May 2, 2020 to the funding source that failed to document specific information to be released.
These findings were discussed with Facility staff during the inspection process.
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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. This will take place on October 1, 2020 and will include all staff hired within the past year.
Random chart reviews will be conducted on a monthly basis to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director. Follow up and further training will be conducted with responsible staff should a record be out of compliance with 709.28 (c)(2).
Client #1 consent to a county agency is unable to be corrected due to the patient has already left treatment.
Client #6 consent to the funding source is unable to be corrected due to the patient has already left 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 a review of client records, the facility failed to ensure that all consent to release forms contained the purpose of disclosure in client records #1 and #6.
Client #1 was admitted on August 18, 2020 and was still active at the time of inspection. A consent to release form was signed and dated on August 18, 2020 and August 21, 2020 to a county agency that failed to document the purpose of disclosure.
Client #6 was admitted on May 2, 2020 and was discharged on July 10, 2020. A consent to release form was signed and dated on May 2, 2020 to the funding source that failed to document the purpose of disclosure.
These findings were discussed with Facility staff during the inspection process.
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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. This will take place on October 1, 2020 and will include all staff hired within the past year.
Random chart reviews will be conducted on a monthly basis to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director. Follow up and further training will be conducted with responsible staff should a record be out of compliance with 709.28 (c)(3).
Client #1 consent to a county agency is unable to be corrected due to the patient has already left treatment.
Client #6 consent to the funding source is unable to be corrected due to the patient has already left 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 a review of client records, the facility failed to ensure that all consent to release forms contained a dated signature of witness in client record #2.
Client #2 was admitted on August 7, 2020 and was still active at the time of inspection. A consent to release form was signed and dated on August 17, 2020 to an individual that failed to include a dated signature of witness.
These findings were discussed with Facility staff during the inspection process.
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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. This will take place on October 1, 2020 and will include all staff hired within the past year.
Random chart reviews will be conducted on a monthly basis to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director. Follow up and further training will be conducted with responsible staff should a record be out of compliance with 709.28 (c)(5).
Client #2 consent is unable to be corrected due to the patient has already left 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 a review of client records, the facility failed to ensure that all consent to release forms contained documentation that the client was offered a copy of each release in client records #2, #4 and #6.
Client #2 was admitted on August 7, 2020 and was still active at the time of inspection. Two consent to release forms were signed and dated on August 28, 2020 to outside providers that failed to include if the client accepted or refused a copy of the release.
Client #4 was admitted on August 13, 2020 and was still active at the time of inspection. A consent to release form was signed and dated on August 31, 2020 to outside provider that failed to include if the client accepted or refused a copy of the release.
Client #6 was admitted on May 2, 2020 and was discharged on July 10, 2020. A consent to release form was signed and dated on May 13, 2020 to outside provider that failed to include if the client accepted or refused a copy of the release.
These findings were discussed with facility staff during the inspection process.
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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. This will take place on October 1, 2020 and will include all staff hired within the past year.
Random chart reviews will be conducted on a monthly basis to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director. Follow up and further training will be conducted with responsible staff should a record be out of compliance with 709.28 (d).
Client #2 consents are unable to be corrected due to the patient has already left treatment.
Client #4 consent to an outside provider is unable to be corrected due to the patient has already left treatment.
Client #6 consent to an outside provider is unable to be corrected due to the patient has already left treatment.
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709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to ensure a complete record of service was documented in client records #2, 4, 5, 6 and #7.
Client #2 was admitted on August 7, 2020 and was still a client at the time of the inspection. The clients record of services was only completed for August 7, 2020.
Client #4 was admitted on August 13, 2020 and was still a client at the time of the inspection. The client's record of service has not been updated since August 26, 2020.
Client #5 was admitted on February 24, 2020 and was discharged on April 3, 2020. The client's record of services stopped at March 27, 2020.
Client #6 was admitted on May 2, 2020 and was discharged on July 10, 2020. The client's record of service stopped at June 14, 2020.
Client #7 was admitted on April 10, 2020 and was discharged on May 5, 2020. The client's record of service stopped at April 11, 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Nursing and Clinical staff will be retrained on completing the Record of Service with each face to face interaction. Training will be held on October 12th. Evidence of attendance will be maintained in the facility training files.
Random chart reviews will be conducted on a monthly basis to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director. Follow up and further training will be conducted with responsible staff should a record be out of compliance with 709.53 (a)(3).
Client records that were reviewed during the onsite facility inspection have been corrected to reflect each service on the Record of Service.
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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 client records, the facility failed to complete, and document follow up information in two of three applicable records.
Client #5 was admitted on February 24, 2020 and discharged on April 3, 2020.
Client #7 was admitted on April 10, 2020 and discharged on May 5, 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Clinical staff will be retrained on completion and documentation of follow up for each client record. Training will be held on October 12th. Evidence of attendance will be maintained in the facility training files.
Random chart reviews will be conducted on a monthly basis to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director. Follow up and further training will be conducted with responsible staff should a record be out of compliance with 709.53 (a)(11).
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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