INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 22-24, 2013 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:
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Plan of Correction
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704.8(c) LICENSURE Full Caseload Assignment
704.8. Qualifications for the position of counselor assistant.
(c) In addition to training, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level.
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Observations
Based on a review of personnel files and the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to document a positive assessment of a counselor assistant prior to the assignment of a full caseload in two of eleven records reviewed.
The findings include:
Eleven personnel records were reviewed for the position of counselor assistant during an administrative site review on April 2, 2013. The facility failed to document a positive assessment prior to assigning a full caseload for two of those employees, specifically employees # 21 and 25.
Employee # 21 assumed the position of counselor assistant on January 21, 2013. After a review of employee #21's personnel file, it was found they had not obtained documentation of a positive assessment the state their capability of handling a full caseload. The SRFSR, signed by the project director on April 1, 2013 lists employee #21 as having a full caseload of eleven clients.
Employee # 25 assumed the position of counselor assistant on December 31, 2012. After a review of employee #25's personnel file, it was found they had not had documentation of a positive assessment stating their capability of handling a full caseload. The SRFSR, signed by the project director on April 1, 2013 lists employee #25 as having a full caseload of twelve clients.
This was discussed with the director of quality assurance and facility director during the exit interview.
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Plan of Correction
Clinical Supervisor will complete positive assessment on counseling staff as needed. Clinical Supervisor will meet with Clinical Director to review counselors' progress and positive assessment prior to assignment of full caseload.
After reviewing with clinical director, Clinical supervisor will meet with counselor to discuss progress and review positive assessment. Upon completing the positive assessment review with counselor, clinical supervisor will scan a copy of the positive assessment to QI coordinator for tracking.
Clinical Director will meet with supervisors to discuss this process, supervisors will acknowledged this supervision via co-signing supervision note and it will be documented in a supervision note dated: 5/22/13
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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 employee personnel record, the facility failed to document the required period of close observation for one counselor assistant.
The findings include:
Eleven personnel records were reviewed for the position of counselor assistant on April 2, 2013. The facility failed to document appropriate supervision for one of those employees, specifically employee # 19.
The counselor assistant represented in record # 19 was hired as a counselor assistant on October 3, 2012. Employee #19 has a Bachelor of Arts degree in History and a Master ' s of Education degree, however the Master's degree, nor the transcripts indicated a concentration in secondary education. Neither degree presented would qualify for the position of counselor which would make employee #19 a high school level counselor assistant who is required for have direct observation for the first 3 months of employment and close supervision for the next 9 months.
As of the date of inspection, employee # 19 had direct observation documented until December 28, 2012 and close supervision documented until March 25, 2013. Employee #19 is required to have close supervision for at least another 3 months.
The lack of documentation was reviewed with the director of quality assurance and the facility director during the exit interview.
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Plan of Correction
Supervisor will continue to document close supervision with employee #19. Supervisor will conduct close supervision with employee #19 for the required 9 months, if she fails to conduct supervision for a week that week will be added to the total, until close supervision is completed, 10/3/13.
Employee #19s supervisor has been met with to be made aware of this situation and has agreed to continue with close supervision. This has been documented in supervision dated: 5/15/13.
QI Coordinator will monitor, collect and document supervisions for counselor assistants as well as counselors (as needed). If clinical supervisor fails to document required supervisors, Clinical director will be alerted and disciplinary actions may occur for clinical supervisor responsible.
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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 an inspection of the physical plant, the facility failed to ensure that hot water temperatures did not exceed 120 degrees Fahrenheit (F).
The findings include:
A physical plant inspection was conducted on April 23, 2013 at approximately 10 AM. During the inspection, the water in building #11 in bathroom #1 measured 124 F; the water in the bathrooms in room #3 and #7 in building #24 both measured 128 F; and the water in building #25 in room #25-4 measured 148 F, #25-7 measured 126 F, #25-8 measured 140 F, #25-3 measured 142 F, and #25-9 measured 137 F.
The findings were confirmed by the maintenance director and campus director during the inspection.
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Plan of Correction
Director of Maintenance contacted maintenance department about the water temperature, this was corrected while auditors were on-site.
Correction was confirmed by supervisor of maintenance department on 4/24/13.
Maintenance department will keep a monthly temperature check using a digital thermometer, per facility surveillance report. This report will be checked by the program maintenance supervisor quarterly for compliance.
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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to ensure that exits from the facility were unobstructed.
The findings include:
A physical plant inspection was conducted with the program assistant on April 23, 2013 at around 10:00 AM. During the inspection it was found that the second (rear) exit, from the building #16, was difficult to open and required an excessive amount of force to function.
This was confirmed by a maintenance technician who was present during the inspection.
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Plan of Correction
Director of Maintenance informed maintenance department of violation, maintenance shaved down the rear exit door the following weekend to aid in ease of entrance/exit from the building as well as prevent from further sticking.
Correction was confirmed by supervisor of maintenance department on 4/29/13.
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705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based upon the physical plant inspection and information provided by the Facility Director, the facility failed to maintain at least one ABC rated fire extinguisher per each 2,000 square feet of floor space or fraction thereof.
The findings include:
The physical plant inspection was conducted on April 23, 2013 at approximately 10:00 AM. In building # 23, the facility maintained three portable ABC rated fire extinguishers, which were sufficient for 6,000 square feet of floor space. However, the floor plan for building # 23 indicated that the facility occupied approximately 6,253 square feet. Therefore, the facility was required to maintain four portable ABC fire extinguishers.
The findings were confirmed by the Maintenance Director during the inspection and again during the exit interview.
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Plan of Correction
On 4/24/13, Maintenance Director informed Maintenance staff of violation. During inspection this violation was corrected and an ABC rated extinguisher was placed in the residential hallway of building #23 to correct having 4 fire extinguishers in the designated space.
Correction was confirmed by supervisor of maintenance department on 4/24/13.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff were instructed on the use of fire extinguishers upon employment.
The findings include:
During the administrative review on April 3, 2013, twenty personnel records were reviewed for documentation of fire extinguisher training. The facility failed to document the completion of fire extinguisher training upon hire in six personnel records reviewed, specifically employees # 6, 8, 18, 20, 25, and 26.
Employee # 6 was hired on 9/12/12; fire extinguisher training had not been documented until 11/12/12.
Employee # 8 was hired on 3/20/13; fire extinguisher training had not been documented at the time of review.
Employee # 18 was hired on 10/15/12; fire extinguisher training had not been documented until 11/14/12.
Employee # 25 was hired on 9/17/12; fire extinguisher training had not been documented until 10/10/12.
Employee # 26 was hired on 7/12/12; fire extinguisher training had not been documented until 7/25/12.
The findings were confirmed by the director of quality assurance during the licensing inspection on April 22, 2013.
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Plan of Correction
QI coordinator receives a list of all new hires and their start dates, QI coordinator will schedule time within the first 3 days of hire with new hires direct supervisor for new hire to meet with QI Coordinator and/or Safety management within the initial 7 days of hire so that new hires can be oriented to fire extinguisher training. In the event that employee fails to attend during the schedule time (first 3 days of hire), supervisor/clinical director will be contacted by QI coordinator and/or safety management staff and a new appointment will be scheduled within the next 3 (days 4-6) days. If employee again fails to attend, HR department/supervisor and clinical director will be notified and new hired employee will be removed from the schedule and not be able to return to work until this training has been conducted/completed. This will be documented utilizing the CARF safety training form, which the staff will sign/date upon review.
This process has been initiated starting 5/28/13.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained upon employment to perform assigned tasks during emergencies.
The findings include:
During the administrative review on April 3, 2013, twenty personnel records were reviewed for documentation of emergency training. The facility failed to document the completion of emergency training upon hire in six personnel records reviewed, specifically employees # 6, 8, 18, 20, 25, and 26.
Employee # 6 was hired on 9/12/12; emergency training had not been documented until 11/12/12.
Employee # 8 was hired on 3/20/13; emergency training had not been documented at the time of review.
Employee # 18 was hired on 10/15/12; emergency training had not been documented until 11/14/12.
Employee # 25 was hired on 9/17/12; emergency training had not been documented until 10/10/12.
Employee # 26 was hired on 7/12/12; emergency training had not been documented until 7/25/12.
The findings were confirmed by the director of quality assurance during the licensing inspection on April 22, 2013.
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Plan of Correction
QI coordinator receives a list of all new hires and their start dates, QI coordinator will schedule time within the first 3 days of hire with new hires direct supervisor for new hire to meet with QI Coordinator and/or Safety management within the initial 7 days of hire so that new hires can be oriented to fire emergency training. In the event that employee fails to attend during the schedule time (first 3 days of hire), supervisor/clinical director will be contacted by QI coordinator and/or safety management staff and a new appointment will be scheduled within the next 3 (days 4-6) days. If employee again fails to attend, HR department/supervisor and clinical director will be notified and new hired employee will be removed from the schedule and not be able to return to work until this training has been conducted/completed. This will be documented utilizing the CARF safety training form, which the staff will sign/date upon review. This process will be initiated starting 5/28/13.
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project.
The findings include:
One client record was reviewed for documentation of a termination letter on April 16, 2013. One of one client record reviewed failed to include notification to the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in a timely manner, specifically client record # 14.
Client # 14 was admitted to the program on November 1, 2012 and was involuntarily terminated from the program on January 7, 2013. The client did not receive notification of the decision to involuntarily terminate treatment until February 22, 2013.
The findings were reviewed with the site director during the exit interview.
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Plan of Correction
Effective 5/15/2013, WDR Staff will inform patients of the decision to terminate them from treatment. Staff will ask patient to sign termination form which will outline the purpose of termination from treatment. If patient refuses to acknowledge this or sign the form, staff will mail a copy of the form/letter informing them of their discharge/termination from treatment to the client with a copy of the appeal process and form. Staff will write on communication sheet whether they gave client a copy of the form or whether it was mailed and when to the client.
Medical records and supervisor will audit 10 charts monthly to track that these forms are being utilized and that the letters are being documented on the communication log.
QI Coordinator will track administrative discharges from the program and document whether this form was used and send to clients
Clinical Director met with supervisors they acknowledge this process and it has been documented in supervision note dated 5/15/13. Supervisors will meet with the clinical staff to inform them verbally and in writing of this process and their role in maintaining compliance regarding termination letters.
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709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of inpatient client records, the facility failed to document discharge summaries according to facility policy in two of six records reviewed.
The findings include:
Facility policy states that discharge summaries will be completed within seven days of discharge.
Six client records requiring documentation of a discharge summary were reviewed on April 23, 2013. The facility failed to document discharge summaries within seven days of the client being discharged in two of six records reviewed, specifically records # 9 and 12.
Client # 9 was admitted into inpatient treatment on February 17, 2013 and was discharged on February 19, 2013. The facility did not document a discharge summary for this client until March 29, 2013.
Client # 12 was admitted into treatment on February 21, 2013 and was discharged on March 1, 2013. The facility did not document a discharge summary for this client until April 3, 2013.
The Facility Director confirmed the findings.
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Plan of Correction
The Clinical Supervisors will re-educate the counselors on completing discharge summaries on all clients within seven days. This will be done in writing and verbally by 6/30/13.
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. Communication to occur between the Medical Records Manager, QI Coordinator and Clinical Director.
By May 22nd, the Clinical Director will review the findings with the supervisors.
The focus was the timeliness of completing discharge summaries.
The Medical records technicians and Supervisors will complete chart audits with a focus on discharge summaries A minimum of 10 charts will be monitored monthly.
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