INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 23-24, 2023 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 a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide direct observation by a trained counselor or clinical supervisor for the first 3 months of employment or for the next 9 months, under close supervision.Employee #15 was hired on August 9, 2022 and was still employed at the time of the inspection. He had no documentation of direct and close supervision.Employee #17 was hired on June 27, 2022 and was still employed at the time of the inspection. He had no documentation of direct and close supervision. Employee #18 was hired on October 17, 2022 and was still employed at the time of the inspection. She had no documentation of close supervision.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Direct and close supervision was completed and minimally documented on employees #15, 17, and 18,however, documentation around the specifics of their direct and close supervision was missing. It was advised during the on-site inspection that specific patient numbers be added as well as specifics around group/individual sessions be added to meet this regulation.
On 4/7/23 Clinical director met with clinical supervisors to review the outcome of the inspection and reviewed expectations on how to document supervision for all counselors and counselor assistants, including the importance of identifying specific information that addresses that direct and close supervision was conducted by using patient numbers and timeframes/themes/topics noted during group and individual observations, as well as outcomes and needs.
Clinical director will review a sampling of 5 supervisions monthly to ensure that clinical supervision is being conducted that includes direct and close supervision. If it is noted that supervision continues to not be documented appropriately, further training and supervision will occur with clinical supervisor(s).
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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 a physical plant inspection, it was observed that the facility failed to maintain hot water not exceeding 120 degrees. Building 25, room 2's hot water temperature was recorded at 128; room 4's hot water temperature was recorded at 134; and room 8's hot water temperature was recorded at 128.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility correct the water temperature the day of the inspection by adjusting the water heaters and checking the water temperature until it was 120 degrees.
The facility management staff will conduct monthly leadership rounds and maintenance department will conduct maintenance rounds where water temperature checks will be noted to ensure that hot water temperatures will not exceed 120 degrees.
If/when it is noted that the temperature is above 120 degrees, staff conducting the leadership rounds and/or maintenance rounds will notify maintenance team to have the temperature adjusted through the water heater and testing the temperature until correct, immediately.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ventilate toilet and bathrooms by exhaust fan or window. The ventilation fans in the bathrooms in building 7B suite KSL and building 11 suite 2 were inoperable.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility corrected the issue of the fan on working in building #11, room 2 and building #7 room KSL the day of the inspection by replacing the exhaust fan with a new one.
The facility management staff will conduct monthly leadership rounds and maintenance department will conduct maintenance rounds where bathroom exhaust fans will be checked to ensure they are in working order.
If/when it is noted that the exhaust fan is not working properly, staff conducting the leadership rounds and/or maintenance rounds will notify maintenance team to have the exhaust fans looked at and repaired/replaced as necessary.
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705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection, the facility failed to store all food items off the floor. There were cans of food on the floor in the storage area. This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Dietary manager will remove cans from the floor and either shelve them or dispose of them if they are damaged/expired.
Dietary manager will conduct weekly inspection of food storage areas to ensure that food is not being stored on the floor.
If food is being stored on the floor dietary manager will meet with dietary staff to review the importance of adherence to regulation 705.7 (b) and correct the issue immediately.
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguisher in the basement storage area was not inspected in the last year. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Outdated extinguisher was removed and replaced with inspected extinguisher.
Security team will conduct monthly inspection of fire extinguishers to ensure that all extinguishers are inspected and approved annually by a local fire extinguisher company.
Extinguishers found to be inappropriately charged or outdated will be removed and replaced by security team, with an extinguisher that has been charged and inspected within the past year.
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