INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on April 24-25, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite 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 the inspection:
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Plan of Correction
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705.6 (1) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(1) Provide bathrooms to accommodate staff, residents and other users of the facility.
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Observations
The facility failed to ventilate toilets and wash rooms with an operable fan or window.The physical plant inspection was conducted on April 25, 2017 at approximately 1:00 PM. Seven exhaust fans located in various buildings on the facility property were found to be inoperable at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance staff ordered parts to fix the defective fans in building # 25, additionally a new ceiling exhaust unit was installed in the public bathrooms in building # 25.
Maintenance staff ordered and installed new fans in the bathrooms of building #5.
All bathroom fans identified during the walk through have been fixed or replaced.
The facility will ensure that the fans are working on a weekly basis through the use of leadership rounds (internal building inspection) conducted by the facility management team as well was monthly maintenance walk through (internal physical plant/facility inspection). |
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
The facility failed to document a complete client record including discharge summaries in three of three inpatient client records.Three discharged inpatient client records were reviewed on April 24-25, 2017. All three client records were required to include documentation of a discharge summary. Client records #6, 7 and 8 did not have documentation of a discharge summary.Client #6 was admitted on 9/25/16 and discharged on 10/20/16. There was no discharge summary documented in client record #6.Client #7 was admitted on 11/28/16 and discharged on 12/24/16. There was no discharge summary documented in client record #7.Client #8 was admitted on 11/28/16 and discharged on 12/13/16. There was no discharge summary documented in client record #8.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisors will re-educate the counselors during clinical supervision on regulatory standards/timeframes, time management and therapeutic boundaries, this will be completed in writing and verbally by 6/23/17.
Clinical supervisors will develop a schedule for clinical staff to have an hour weekly to work on their required paperwork. This schedule will be developed and implemented by 6/23/17
Medical Records staff will conduct ongoing monitoring of discharge summaries and report to the clinical director/supervisors when counselors are not completing them in in a timely manner.
Ast. Clinical Director will audit 12 charts weekly for 3 months, with a focus on discharge summaries to ensure that discharge summaries are being completed within regulatory guidelines. Findings from the medical records and Ast. Clinical Directors audits will be reviewed during weekly supervisors meetings.
Counselor Ast and Counselors will have their Clinical supervisors review and co-sign their completed discharge summaries.
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