INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 12 through 13, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Perspectives at White Deer 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 and a plan of correction is due on May 9, 2010.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on the review of the Staffing Requirements Facility summary report and an interview with the Facility Director on April 12, 2010, the facility failed to ensure that the Clinical Supervisor only carried five clients on their caseload.
The findings include:
The Staffing Requirements Facility Summary report was reviewed on April 12, 2010. The Clinical Supervisor was carrying a caseload of 12 clients. In an interview with the Facility Director On April 12, 2010, it was confirmed that the Clinical Supervisor exceeded the number of clients permitted to be carried on the Clinical Supervisor's caseload.
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Plan of Correction
Plan of Correction:
In accordance with
704.6 which reads: "Qualifications for the position of a clinical supervisor. (a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both."
An outpatient counselor will be hired to fulfill this requirement effective May 17, 2010, ensuring that the Clinical Supervisor has no more than 5 clients on his/her caseload.
Clinical Supervisor will continue to follow up and maintain compliance with this regulation.
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of administrative policies and procedures and an interview with the facility director, the facility failed to provide documentation of a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric coverage.
The findings include:
The administrative policies and procedures were reviewed on April 6 through 7, 2010. The facility director was interviewed at the time of the on-site inspection on April 12, 2010. The facility director was unable to provide a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric coverage, as required by the regulation.
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Plan of Correction
Plan of Correction:
In accordance with 709.24 which reads: "Treatment/rehabilitation
management. Provisions
will be made, through
written agreement with
a licensed hospital or agency for 24-hour emergency psychiatric and medical coverage.
The Regional Office Manager will obtain a written agreement for 24 hour medical and psychiatric coverage no later than May 17th, 2010 and will be responsible to insure agreement remains in place on an ongoing basis through supervision by Regional Director.
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709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Based on a review of administrative policies and procedures, client records, and an interview with the facility director, nurse coordinator and a review of medication logs that record medication administration, the facility failed to document an accounting of medications administered to patients in accordance with facility policy and procedures.
The findings include:
Base on a review of administrative policies and procedures which occurred on April 5 through 6, 2010 and an onsite inspection of facility medication logs on April 13, 2010, and a discussion with the facility director and nurse coordinator, the medication log sheets did not include complete documentation of narcotic medication administered to patients. The narcotic sign-out sheet for April 11, 2010, was missing information as the record did not contain the patient's complete name, directions, quantity dispensed, and the staff person dispensing the medication.
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Plan of Correction
Plan of Correction:
Reviewed medication management procedures including accountability and documentation at nurse's meeting held 4/29/10 conducted by Lead Nurse and Campus Director.
Nursing Staff will follow policy and procedures for medication administration as outlined in the facility plan and in accordance with State Regulations.
Nursing supervisor will ensure that policies are followed and administration is in compliance through direct observation, monitoring of the medication administration record and through monthly auditing of the charts.
The Campus Director will be responsible for monitoring the follow up and ongoing compliance by the Nursing Supervisor.
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