INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 14, 2021 through April 16, 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, Inc. 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 twenty-eight personnel records, the project failed to ensure that six of twelve counselor assistants reviewed received direct observation and/or close supervision that is in compliance with the regulatory timeframes.Employee #18 was hired as a counselor assistant on December 21, 2020 and was a current employee at the time of the inspection. Since employee #18 was hired with a qualifying Master ' s Degree, but with no previous clinical experience, the employee was to only counsel clients under the close supervision of a trained counselor or clinical supervisor for at least the first three months of employment; however, there was no documentation in the personnel record of close supervision for the month of January 2021, which entails one hour of documented case review per week and one hour of documented direct observation per week.Employee #20 was hired as a counselor assistant on February 8, 2021 and was a current employee at the time of the inspection. Since employee #20 has a high school diploma, the employee is to only counsel clients under the direct observation of a trained counselor or clinical supervisor for the first three months of employment; however, there was no documentation in the personnel record of direct observation. Employee #21 was hired as a counselor assistant on December 28, 2020 and was a current employee at the time of the inspection. Since employee #21 was hired with a qualifying Bachelor ' s Degree, but with no previous clinical experience, the employee was to only counsel clients under the close supervision of a trained counselor or clinical supervisor for at least the first six months of employment; however, there was no documentation in the personnel record of close supervision for the months of February 2021 and March 2021, which entails one hour of documented case review per week and one hour of documented direct observation per week.Employee #23 was hired as a counselor assistant on February 2, 2021 and was a current employee at the time of the inspection. Since employee #23 was hired with a qualifying Bachelor ' s Degree, but with no previous clinical experience, the employee was to only counsel clients under the close supervision of a trained counselor or clinical supervisor for at least the first six months of employment; however, there was no documentation in the personnel record of close supervision which entails one hour of documented case review per week and one hour of documented direct observation per week. Employee #26 was hired as a counselor assistant on January 4, 2021 and was a current employee at the time of the inspection. Since employee #26 was hired with a qualifying Master ' s Degree, but with no previous clinical experience, the employee was to only counsel clients under the close supervision of a trained counselor or clinical supervisor for at least the first three months of employment; however, there was no documentation in the personnel record of close supervision which entails one hour of documented case review per week and one hour of documented direct observation per week.Employee #27 was hired as a counselor assistant on November 8, 2020 and was a current employee at the time of the inspection. Since employee #27 has a high school diploma, the employee is to only counsel clients 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; however there was no documentation in the personnel record of close supervision for the month of March 2021, which entails one hour of documented case review per week and one hour of documented direct observation per week. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Quality improvement director has updated the supervision form to specifically include 1 hour of observation and 1 hour of case review for counselor assistants and has distributed the form to clinical supervisors.
Clinical director met with clinical supervisors on 4/23/21 to review the supervision expectations of counselors assistants as outlined in regulation 704.9.
Counselors assistants will received supervision as outlined in regulation 704.9 and clinical supervisors will document the supervision on the updated supervision form.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on the physical plant inspection, completed on April 15, 2021, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.All dumpsters throughout campus were observed to be open or partially open.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance staff will contact waste management company to get replacement dumpsters to ensure that the sliding metal animal proof lids will close.
Maintenance staff during their daily rounds will monitor the dumpsters to ensure that lids are closed.
Facility COO/CFO will speak with dietary and housekeeping supervisor to ensure that their staff are educated on regulation 705.2 and the expectations around keeping dumpsters closed after use.
Facility leadership will conduct weekly leadership rounds to assess repairs/maintenance around the facility and report physical plant issues to maintenance staff who will repair as needed.
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection, completed on April 15, 2021, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit.When tested with a thermometer, the water temperature in building #23, measured at 138.7 degrees Fahrenheit.When tested with a thermometer, the water temperature in building #25, measured at 128.3 degrees Fahrenheit.When tested with a thermometer, the water temperature in the detox building, measured at 135.7 degrees Fahrenheit.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance staff reset the hot water thermostats to be within 120 degrees Fahrenheit and completed check to ensure temperature was accurate.
Facility leadership will conduct weekly leadership rounds to assess repairs/maintenance around the facility and report physical plant issues to maintenance staff who will repair as needed.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the physical plant inspection, completed on April 15, 2021, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.In the female bathroom in building #22 a broken drain with standing water in it was observed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance staff replaced the drain cover on 4/15/21.
Facility leadership will conduct weekly leadership rounds to assess repairs/maintenance around the facility and report physical plant issues to maintenance staff who will repair as needed.
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on the review of patient records, the program failed to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least one year prior to admission for maintenance treatment in one of eight applicable patient records reviewed.Patient #6 was admitted on January 22, 2021 and was discharged on February 19, 2021. Patient #6 was administered the first maintenance dose of methadone on January 24, 2021; however, a narcotic treatment physician had not conducted the face-to face determination of whether the patient was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year until January 27, 2021. These findings were reviewed with program staff during the licensing process.
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Plan of Correction
All opiate dependent patients will meet with the physician face to face to complete a history and physical prior to the ordering and administration of methadone.
The physician will meet face-to-face with the patient to make a determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
The NTP Provider(s) will receive a list of patients the provider is to meet with for a face to face/History and Physical at the start of the day from the nights previous opiate dependent admissions. The charge nurse will provide the list to the Provider(s).
The NTP Provider (s) will meet with the patient and then report back to the charge nurse for each patient on what the treatment plan will be (detox/ MAT).
The charge nurse will check in the EMR for each patient to confirm the History and Physical was completed and to verify the medication orders.
The dayshift charge nurse will monitor this daily in order to ensure compliance.
The COO/Director of Medical Services will be responsible to ensure the corrective action has been implemented.
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