INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 4, 2019 of White Deer Run Lancaster by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, White Deer Run Lancaster 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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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
Based on a review of the project's policy and procedure manual, position descriptions, and an interview with facility staff, the project failed to ensure that the staff persons meet the educational and experiential qualification requirements of chapter 704.
The position description for the Director of Program Management, also known as the Facility Director, does not include the requirement that the person have experience in program planning.
The facility staff stated that their Counselor 2 position, was the equivalent of a counselor as per the Department of Drug and Alcohol Programs staffing regulations. However, the position description for a Counselor 2, only requires a high school diploma, and not an Associate degree or higher.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR department ensure the need for experience in program planning as a qualification for the Facility Director role will be added to the system's job description.
The line stating that a high school diploma is acceptable for a Counselor level position will be removed from the Counselor 2 job description by the HR manager. A line stating the education requirement for a counselor is a minimum of an associate's degree in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in human services) or other related field will be added by the HR manager.
The executive director's designee will review the project's policies and procedures against DDAP regulations annually to ensure compliance.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #4 and #6 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #4 was hired as a counselor on May 22, 2017 and was due to have the communicable disease trainings no later than May 22, 2018. Employee completed TB/STD training on March 12, 2019 and HIV/AIDS training on March 27, 2019.
Employee #6 was hired in housekeeping on July 13, 2015 and was due to have the communicable disease trainings no later than July 13, 2017. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility Director and department managers will ensure employees receive a minimum of 6 hours of HIV/AID training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe. Upon completion of required trainings, employees will submit certificates of training to the Quality Improvement Manager for employee training files. Compliance will be monitored through record reviews by the Quality Improvement Manager and HR Department on a monthly basis. Results of record reviews will be shared with the Facility Director and department managers.
Employee #4, a counselor has completed TB/STD training on March 12, 2019 and HIV/AIDS training on March 27, 2019. No further action needed for her. Employee #6, housekeeper will attend her missing HIV/AIDS training through the facility on 5/30/19 and the certification of completion will be sent to the Quality Improvement Manager for the employee's training file.
The executive director's designee will review employee trainings regularly along with the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
A review of the March 2018 through February 2019 fire drill logs was conducted during the onsite inspection. The facility failed to conduct unannounced drills during the 2018 months of June and July.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will identify an onsite Safety Officer. The Risk Manager will review policy and procedures regarding monthly unannounced drills with the Safety Officer, including the requirement for drills to be completed on all shifts and at least one night time fire drill every 6 months. The Safety Officer will conduct the monthly unannounced fire drills. Documentation of fire drills will be filled in the Health and Safety binder under the fire drill section. Compliance will be monitored on a monthly basis by the Safety Officer, Risk Manager and the Health and Safety Committee.
The undocumented 2018 June and July drills cannot be made up.
The executive director's designee will review these drills regularly along with the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy or procedure for utilization of volunteers.
These findings were reviewed with facility during the licensing inspection.
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Plan of Correction
The executive director will create a policy in relation to volunteers for the system.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of the project's policy and procedure manual, the project's confidentiality policy does not include 4 Pa. 255.5(a)(6) identifying the limitation of information that may be disclosed to employers or prospective employers of the client. In addition, project's policy and procedure manual does not identify the person responsible for maintaining electronic records.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will revise the confidentiality policy so it includes the limitation of information that may be disclosed to employers of the client.
The executive director will revise the confidentiality policy to include identification of the person responsible for maintaining electronic records.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance. |
709.28 (a) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
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Observations
Based on a review of the project's policy and procedure manual, the project's procedures do not address the methods by which staff gain access to electronic records.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will revise the confidentiality policy so it addresses the methods by which staff gain access to medical records.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the project's policy and procedure manual, the project failed to include in its policies that that the project may not discriminate in the provision of services based on age, ethnicity, marital status and/or creed.
The Intake and Admission Continuum of Care Policy and Procedure for Intake and Admissions for Partial Hospital, Outpatient Part II and Adult Admission Criteria Part II, does not include age, ethnicity, and marital status for those who will not be discriminated against.
In the project's Rights Responsibilities and Ethics (RI), subject "Patients Rights" Policy and Procedure, Under Procedure: A. 1. "creed" is not included.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director will revise the patient rights so they include that the project may not discriminate in the provision of services based on age, ethnicity, marital status and/or creed.The executive director will add "creed" to the Rights Responsibilities and Ethics subject "Patient Rights" policy and procedure A.1. section.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance
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709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy or procedure for documentation of medication administration when self-administered by the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will revise the current policy that exists on medication administration and self-administration so it includes reference to the current self medication documentation form.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy relating to maintaining copies of drug-related regulations being available in appropriate areas.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will add a policy that addresses the need to maintain copies of drug-related regulations in appropriate areas to the regional policy and procedure manual.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Based on a review of the project ' s policy and procedure manual, the project does not have a procedure in place to address the requirements in 715.22(b).
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director will revise the current grievance procedure so it addresses permitting patients to have a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director and to address grievances filed by patients against the narcotic treatment program director.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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715.22(c) LICENSURE Patient grievance procedures
(c) Penalties may not be initiated prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to commit acts of physical violence in or around the narcotic treatment program premises.
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Observations
Based on a review of the project ' s policy and procedure manual, the project does not have a procedure in place to address the requirements in 715.22(c ).
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director will update the grievance procedure to address penalties being initiated against patients prior to the final resolution of grievances.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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