INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 15, 2011 through March 17, 2011 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on April 16, 2011.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records and an interview with the Quality Improvement Director and the Facility Director, the facility failed to ensure that each counselor met the qualifications for the position in two of fourteen records, as required.Findings:Ninety Six personnel records were reviewed on March 7, 2011 through March 10, 2011. Of the ninety six personnel records fourteen were reviewed for the counselor position, #10, 11, 15, 16, 18, 21, 22, 24, 29, 30, 32, 33, 34 and 38. An interview was conducted on March 9, 2011 with the Quality Improvement Director and she confirmed that counselors # 21 and 30 failed to meet the qualifications for their positions. An interview on March 16, 2011 with the Facility Director confirmed that the counselors failed to meet qualifications for their positions.In personnel record #21, the counselor did not meet the qualifications for the position of counselor based on their Bachelor degree in Anthropology. In addition, a review of the Bachelor degree course transcripts by the Division on March 15, 2011 again confirmed that employee # 21 failed to meet the educational component for the position of counselor. In personnel record #30, the counselor did not meet the qualification for the position of counselor based on not having the required experience or practicum in a heath or human service agency.
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Plan of Correction
The personnel record for employee #21 is that she will receive close (weekly) supervision for the next 9.5 months. This counselor has already received 2.5 months of close (weekly) supervision.
In the case of employee #30, the counselor will be provided the same supervision process as that of a staff member with a Qualifying Degree with no experience, including: weekly supervision for the first 90 days, a positive assessment and monthly supervision thereafter.
Addendum: It is the policy of White Deer Run that all approvals for Counselors and Counselor Assistants are reviewed with Performance Improvement/Quality Improvement Department to ensure that hiring practices are consistent with Department of Health licensing guidelines. Offers to Counselor/Counselor Assistant candidates will not be extended until approval from PI/QI is received noting any required supervision. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of facility staffing summary report and an interview with the Quality Improvement Director and the Facility Director, the facility failed to provide documentation of individual training plans in fifty of ninety six personnel records reviewed.The findings include:Ninety six personnel records were reviewed on March 7, 2011 through March 10, 2011. Individual training plans were required in the ninety six records. The facility did not document individual training plans for the January 1 - December 31, 2011 training year in fifty records reviewed. An interview conducted on March 7, 2011 with the Quality Improvement Director confirmed that the failed to document individual training plans. Also, a discussion took place on March 15, 2011 with the Facility Director and it was confirmed that the training plans were not documented.Employee record #45 was hired on October 29, 2007. An individual training plan was not completed for the 2011 training year.Employee record #46 was hired on May 15, 2005. An individual training plan was not completed for the 2011 training year.Employee record #49 was hired on May 11, 1992. An individual training plan was not completed for the 2011 training year.Employee record #50 was hired on October 1992. An individual training plan was not completed for the 2011 training year.Employee record #51 was hired on November 3, 2010. An individual training plan was not completed for the 2011 training year.Employee record #52 was hired on November 1, 1996. An individual training plan was not completed for the 2011 training year.Employee record #53 was hired on January 10, 2004. An individual training plan was not completed for the 2011 training year.Employee record #54 was hired on February 18, 2010. An individual training plan was not completed for the 2011 training year.Employee record #55 was hired on September 16, 1999. An individual training plan was not completed for the 2011 training year.Employee record #56 was hired on November 14, 1998. An individual training plan was not completed for the 2011 training year.Employee record #57 was hired on May 29, 2002. An individual training plan was not completed for the 2011 training year.Employee record #58 was hired on October 2, 2003. An individual training plan was not completed for the 2011 training year.Employee record #59 was hired on August 1, 1994. An individual training plan was not completed for the 2011 training year.Employee record #60 was hired on May 11, 1992. An individual training plan was not completed for the 2011 training year.Employee record #61 was hired on August 17, 2005. An individual training plan was not completed for the 2011 training year.Employee record #62 was hired on June 5, 1995. An individual training plan was not completed for the 2011 training year.Employee record #63 was hired on June 7, 2009. An individual training plan was not completed for the 2011 training year.Employee record #64 was hired on April 20, 2002. An individual training plan was not completed for the 2011 training year.Employee record #65 was hired on October 20, 2006. An individual training plan was not completed for the 2011 training year.Employee record #66 was hired on September 11, 2006. An individual training plan was not completed for the 2011 training year.Employee record #67 was hired on July 21, 2005. An individual training plan was not completed for the 2011 training year.Employee record #68 was hired on December 19, 2005. An individual training plan was not completed for the 2011 training year.Employee record #69 was hired on May 22, 2003. An individual training plan was not completed for the 2011 training year.Employee record #70 was hired on November 18, 2006. An individual training plan was not completed for the 2011 training year.Employee record #71 was hired on April 20, 2009. An individual training plan was not completed for the 2011 training year.Employee record #72 was hired on May 12, 2009. An individual training plan was not completed for the 2011 training year.Employee record #73 was hired on July 10, 2011. An individual training plan was not completed for the 2011 training year.Employee record #74 was hired on July 10, 2011. An individual training plan was not completed for the 2011 training year.Employee record #75 was hired on October 6, 2010. An individual training plan was not completed for the 2011 training year.Employee record #76 was hired on May 2, 2007. An individual training plan was not completed for the 2011 training year.Employee record #77 was hired on December 30, 2009. An individual training plan was not completed for the 2011 training year.Employee record #78 was hired on July 9, 2008. An individual training plan was not completed for the 2011 training year.Employee record #79 was hired on February 14, 1994. An individual training plan was not completed for the 2011 training year.Employee record #80 was hired on April 29, 2008. An individual training plan was not completed for the 2011 training year.Employee record #81 was hired on October 16, 2010. An individual training plan was not completed for the 2011 training year.Employee record #82 was hired on July 26, 2009. An individual training plan was not completed for the 2011 training year.Employee record #83 was hired on July 18, 2009. An individual training plan was not completed for the 2011 training year.Employee record #84 was hired on November 4, 2008. An individual training plan was not completed for the 2011 training year.Employee record #85 was hired on January 30, 3010. An individual training plan was not completed for the 2011 training year.Employee record #86 was hired on February 10, 2010. An individual training plan was not completed for the 2011 training year.Employee record #87 was hired on May 3, 2010. An individual training plan was not completed for the 2011 training year.Employee record #88 was hired on October 26, 2010. An individual training plan was not completed for the 2011 training year.Employee record #89 was hired on May 5, 2008. An individual training plan was not completed for the 2011 training year.Employee record #90 was hired on August 1, 2009. An individual training plan was not completed for the 2011 training year.Employee record #91 was hired on April 28, 2010. An individual training plan was not completed for the 2011 training year.Employee record #92 was hired on April 7, 2010. An individual training plan was not completed for the 2011 training year.Employee record #93 was hired on May 10, 2010. An individual training plan was not completed for the 2011 training year.Employee record #94 was hired on June 1, 2010. An individual training plan was not completed for the 2011 training year.Employee record #95 was hired on August 31, 2010. An individual training plan was not completed for the 2011 training year.Employee record #96 was hired on October 28, 2010. An individual training plan was not completed for the 2011 training year.
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Plan of Correction
For the 50 staff members who did not have training plans on file at the time of the survey, and are still employed at White Deer Run will have the plans completed and forwarded to QI/PI by April 15, 2011.
One missing training plan noted is for a contracted physician who is not required to have a training plan on file.
Several other employees for whom plans were not completed no longer work at the facility and they include #58, 60, 64, 77, 78, 85, 92 and 93.
In order to ensure that this deficiency does not re-occur, training plans for the upcoming year will be completed during the months of November and December by all staff. The completed plans, with their supervisor's signature, will be forwarded to the Regional Administrative Assistant, who will cross reference the list of training plans received with a current employee roster and notify supervisors of staff for whom training plans have not been completed to ensure that all staff have completed training plans. The completed plans will be forwarded to the QI Department by January 15th of each year.
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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, staffing requirements facility summary report and a staff interview, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.The findings include:Ninety six personnel records were reviewed on March 7, 2011 through March 10, 2011. There was no documentation of HIV/AIDS or TB/STD training in nine employee records. Of the nine, one was to have HIV/AIDS and TB/STD training within the first year of employment and the remaining were personnel records were required to contain documentation of HIV/AIDS and TB/STD training within the two years of employment. An interview conducted on March 7, 2011 with the Quality Improvement Director confirmed that the the facility could not provide documentation of HIV/AIDS training. Also, a discussion took place on March 15, 2011 with the Facility Director and he confirmed that they were not documented.Employee #15 was hired March 28, 2008 and was required to have HIV/AIDS & TB/STD training by March 28, 2009. There was no documentation of TB/STD training in the employee's record as of March 10, 2011.Employee #39 was hired November 20, 2006 and was required to have HIV/AIDS & TB/STD training by November 20, 2008. There was no documentation of TB/STD training in the employee's record as of March 10, 2011.Employee #40 was hired June 13, 2008 and was required to have HIV/AIDS & TB/STD training by June 13, 2010. There was no documentation of HIV/AIDS & TB/STD training in the employee's record as of March 10, 2011.Employee #41 was hired November 22, 2006 and was required to have HIV/AIDS & TB/STD training by November 22, 2008. There was no documentation of HIV/AIDS & TB/STD training in the employee's record as of March 10, 2011.Employee #42 was hired February 28, 2004 and was required to have HIV/AIDS & TB/STD training by February 28, 2006. There was no documentation of HIV/AIDS & TB/STD training in the employee's record as of March 10, 2011.Employee #43 was hired November 3, 2008 and was required to have HIV/AIDS & TB/STD training by November 3, 2010. There was no documentation of HIV/AIDS training in the employee's record as of March 10, 2011.Employee #44 was hired February 26, 2007 and was required to have HIV/AIDS & TB/STD training by February 26, 2009. Employee #44 obtained the required training's March 14, 2011 for HIV/AIDS and March 10, 2011 for TB/STD making it late from the required time of February 26, 2009. Employee #45 was hired October 29, 2007 and was required to have HIV/AIDS & TB/STD training by October 29, 2009. Employee #44 obtained the required training's March 14, 2011 for HIV/AIDS and March 10, 2011 for TB/STD making it late from the required time of October 29, 2009.Employee #46 was hired May 15, 2005 and was required to have HIV/AIDS & TB/STD training by May 15, 2007. Employee #46 obtained the required training October 19, 2010 for HIV/AIDS making it late from the required time of May 15, 2007.
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Plan of Correction
Of the staff identified by the surveyors as having not had the required training(s) completed within the two year time frame, all but 1 has completed the mandatory training(s). Employee #43, who was hired November 3, 2008, separated from employment from this facility on April 23, 2010.
In order to prevent a re-occurrence of this performance deficiency, the Nurse Educator who is responsible for facilitating the HIV and the TB/STD trainings will justify her records of attendees with the Quality Improvement Technician on a monthly basis so that information that is retained at the facility is consistent with the information that is contained in QI. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a physical plant tour and an interview with the Safety/Risk Supervisor and Facility Director, the facility failed to ensure that the facility was free of rodent and insect infestation.The findings include:The physical plant tour took place on March 17, 2011. At around 12:30 PM, during the tour of the facility's physical plant, lady bugs were found in clients' soap dispensers and also in light fixtures. The following buildings had dead lady bugs in the client's soap dispensers, #17F, 2, 5, 7A and 7B. Also, in the following buildings they had dead lady bugs in the light fixtures and windowsills, #3, 4 and 23. An interview with the Safety/Risk Supervisor and Facility on March 17, 2011 confirmed that they do have a problem with lady bugs and currently have a pest control company in place to try to control the outbreak of lady bugs on the campus.
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Plan of Correction
The Asian Beetle, which was introduced to the United States by the Federal Government to reduce the damage caused by Gypsy Moths, while not protected by the Federal Government, citizens are discouraged from destroying them. This Beetle that looks similar to the Lady Bug (which is protected), while a nuisance does not pose a threat of infection or disease. There is a noticeable increase in the number of Asian Beetles around the facility during the months of March and September. Asian Beetles are attracted to white surfaces, which happens to be the color of every building on the campus. The following steps are planned in order to respond to the survey findings. Affected soap dispensers will be replaced to provide a better seal to prevent entry. Housekeeping staff have eliminated the vast majority of Asian Beetles from light fixtures and window sills. An Asian Beetle control treatment by Douty's Pest Control will be completed by Friday, April 15, 2011. The Maintenance Department will also place Diatomaceous Earth (also a non-toxic treatment that shreds the bodies of insects and beetles) around all of the residence buildings when weather permits and to be completed no later than May 1, 2011.
Addendum: A policy and procedure to address the infestation of Asian Beetles will be placed in the Safety and Risk Management Manual by April 20, 2011 and will outline the measures taken during the most severe months of infestation. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and a discussion with the Facility Director, the facility failed to document psychosocial evaluations in ten of twenty three residential treatment and rehabilitation client records.The finding includes:Thirty two client records were reviewed on March 15, 2011 through March 16, 2011. Psychosocial evaluations were to be documented in seventeen client records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17. The psychosocial evaluations were not documented in ten of seventeen required, #2, 3, 4, 5, 6, 12, 13, 14, 15 and 16. A discussion with the Facility Director on March 17, 2011 confirmed that the psychosocial evaluations did not meet all the components per their policy and procedure for psychosocial evaluations in records reviewed.Policy title: PSYCHOSOCIAL ASSESSMENTPolicy: It is the policy of WDR/CFBHS to complete a Psychosocial Assessment on all patients admitted to the facility.Procedure: 1.) The psychosocial assessment is to be completed within 72 hours after admission.2. The psychosocial assessment will include:* A composite picture of the patient in relationship to the information obtained which may help to identify possible relationships, conditions and causes leading to the patient's current situation.*A clear description of the patient's presenting and underlying problems.* Pain assessment and reassessment when indicated.*The patient's needs or problems that can or cannot be resolved through treatment or that might inhibit treatment.* The patient's assets, strengths or other factors that can contribute to the resolution of identified problems.* The potential or available patient support systems.* Negative factors that might affect treatment.* The patient's preferred coping mechanisms.* Conclusions regarding the patient's appearance, behavior and reaction during the intake process.* Conclusion regarding the patient's attitude toward and ability to, participate in the treatment process.Client records #2, 3, 4, 5, 6, 13, 14, 15 and 16 failed to document the client ' s assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.Also, per the facilities policy and procedure manual, which was reviewed on March 7, 2011 through March 10, 2011, stated that psychosocial evaluation will be completed within 72 of admission. A discussion with the facility director on March 17, 2011 confirmed that the psychosocial evaluations were not documented in record reviewed.Client #17 was admitted on March 1, 2011 and discharged on March 11, 2011, as of March 11, 2011 documentation of the clients psychosocial evaluation was not documented in record reviewed.
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Plan of Correction
The deficiency notes that psycho-social assessments were not documented in 10 of 17 records. During the closing with the surveyors, attention was drawn to the quality of the assessments with no indication that assessments were not done. During the survey, the Regional Director also explained that an exception was approved by DAPL with respect to the timeframe for bio psycho-socials to get completed on patients that were in detox and transferring to rehabilitation units. What was conveyed at the closing of this survey on March 17, 2011 was that the psycho-social assessments titled by White Deer Run as Diagnostic Summaries were inadequate in a number of areas as described under procedure on page 21, #2.
Beginning April 13th, Unit Supervisors will discuss the Diagnostic Summary in their weekly staff meeting qualitative review. A sample of approximately 10% of discharged charts will be reviewed to evaluate the quality of the diagnostic summary. The evaluator of each chart will provide feedback to the supervisor of the staff person having written the diagnostic summary/psycho-social assessment in order to provide follow-up training as necessary.
Addendum: Clinical staff whose diagnostic summaries did not meet all the components of the licensing standards and the White Deer Run policies and procedures pursuant hereto, will be provided additional training by their supervisors to ensure understanding of this requirement. Additionally, new staff will be provided training on assessment, interviewing and treatment planning in order to enhance their clinical reasoning abilities. Since clinicians can only improve in this area, the goal of this response is to describe how clinicians will gain a more expanded depth of knowledge and demonstrate that in their documentation, which will be reviewed monthly. |