INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23-24, 2012 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 Run 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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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based upon a review of the facility's Policy and Procedures Manual and Administrative documentation, the facility failed to make an annual report available to the public upon completion of the 2010 fiscal year ending December 31, 2010.
The findings include:
The Policy & Procedures Manual and Administrative documentation were reviewed as part of an Administrative Review conducted from April 2 - 5, 2012.
Per the Policy & Procedures Manual, the fiscal year runs from January 1st to December 31st.
Administrative documentation presented to Licensing Staff included two proofs of publication dated October 19, 2011 and October 20, 2011 showing that the annual report was available: however, the report was not made available until nearly 10 months following the end of the fiscal year.
The findings were reviewed with the Project Director during the exit interview.
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Plan of Correction
Policy has been revised to read as follows;
SUBJECT: GOVERNING BODY
POLICY: Legal responsibility for White Deer Run, Inc., which includes Cove Forge Behavioral Health System, rests with the Governing Body. The Governing Body is responsible for, but not limited to, selecting the Executive Director of the White Deer Run system, identifying the system's mission and philosophy, and creating and maintaining the organizational structure.
PROCEDURE:
Documentation of legal propriety is available in the form of articles of incorporation and publication of fictitious names for other sites within the system. These documents are available for review upon request.
II. The Executive Director of White Deer Run, Inc. is the person officially responsible to the Governing Body.
III. The Governing Body has adopted specific written policies surrounding the issues of selection for membership, qualifications for membership, criteria for continued membership, frequency of meetings, duties of the Body, etc. These standards and policies are described in the White Deer Run, Inc. By-Laws. The By-Laws are found in the Governing Body Manual. The manual includes organizational charts and other corporate documents.
IV. An annual report is developed at the end of each calendar year that outlines financial performance, activities and accomplishments of that year, and other information pertaining to the company's goals and performance where applicable. The report is made available to the general public upon completion of the financial audit for that calendar year. The report will be available to the public during the second quarter of that year.
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709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
Based upon a review of the Policy and Procedures Manual, the project failed to develop a policy regarding an employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
The findings include:
The Policy & Procedures Manual was reviewed as part of an Administrative Review conducted from April 2 - 5, 2012.
As per the General Work Rules section of the Policy & Procedures Manual, the following documentation was contained in a subsection titled, Employee Personnel Files: "You may inspect your personnel file in the presence of Human Resources or the site Facility Director. You may request copies from your file of any documents that you have previously signed. If you desire, you may add a written statement to your file explaining any disputed item."
As developed, the policy failed to inform employees of their right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from their record.
The findings were reviewed during the exit interview conducted with the Quality / Training Manager and Project Director
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Plan of Correction
The Human Resource Senior Business Partner will add an addendum to the employee handbook which states an employee may indicate, in writing, that he/she wishes to have a disputed item removed from his/her Human Resource File. The revised Employee Handbook will be delivered to current employees no later than June 30, 2012. In the interim, new employees will receive a statement in their new hire packets indicating one's right to dispute, in writing, information they deem inaccurate within their Human Resource file. |
709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
Based upon a review of the Policy and Procedures Manual, the facility's policy on the administration of medication failed to address limitations of individuals authorized to administer medications.
The findings include:
The Policy & Procedures Manual was reviewed as part of an Administrative Review conducted from April 2 - 5, 2012.
The project's policy regarding the administration of medication states: "In the PA Department of Health D&A licensed facilities staff authorized to perform medication administration are licensed medical staff, licensed nursing staff, and consulting pharmacists."
In Pennsylvania, pharmacists are permitted to administer medications but only under limited circumstances; however, the policy fails to delineate those limited circumstances. As of the time of inspection, the consulting pharmacists were not limited in their administration of medication.
The findings were reviewed with the Project Director during the exit interview.
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Plan of Correction
On April 27, 2012 the Medication Labeling, Preparation, Administration and Documentation policy was revised by the Project Director and the Quality Management Director. On May 21, 2012 the Governing Body approved the policy revision. The consulting pharmacist has been removed from the list of designated staff that can administer medications. The Quality Management Director has distributed the policy to the administrators and all key staff. |
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 hot water temperatures do not exceed 120 degrees Fahrenheit.
The findings include:
A physical plant inspection was conducted on April 24, 2012 at approximately 9:30 AM. At the time of the inspection, the water in the bathroom shared between rooms # 3 and 4 in the detox residential dorm measured 124 degrees Fahrenheit. The bathroom in the hallway near bedrooms #3 and 4 also measured 124 degrees Fahrenheit.
The findings were confirmed by the maintenance director and campus director during the inspection.
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Plan of Correction
Upon determining that the water was too hot in the detox dorm, Facility Service Coordinator turned down the temperature on the hot water heater so it now reads below 120 degrees. These bathrooms (as all bathrooms) will continue to be regularly checked by the Facility Service Coordinator for overall safety and temperature of water. This plan of correction is effective immediately. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection the facility failed to ensure that stairways, hallways and exits from rooms and the residential facility were unobstructed.
The findings include: A physical plant inspection was conducted on April 24, 2012 at approximately 9:30 AM. At the time of the inspection, the designated exit located in room # 2 in the "Farm House", had an exit door that was blocked by a dresser, had a slide bolt on the door and was equipped with a hasp and padlock on the door. In addition, the facility had placed a paper sign on the door stating "Not An Exit Alarm will Sound", while the door clearly had an illuminated exit sign above the door.
The findings were confirmed by the maintenance director and campus director during the inspection.
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Plan of Correction
On June 22, 2012 the locks and the dresser were removed from the exit. The facility will ensure that all exits will be maintainted unobstructed at all times. The Facility Service Coordinator will make daily rounds to assure that all exits are operable and unobstructed. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of inpatient client records and the facility's policies and procedures, the facility failed to document aftercare plans in accordance with the facility's policies and procedures.
The findings include:
In reference to the aftercare plan for inpatient clients, the project's policy states:
The aftercare plan is to be completed prior to discharge for inpatient clients and must be signed by the client and counselor.
Two inpatient client records were reviewed for aftercare plans on April 23, 2012. One out of two inpatient client records lacked an aftercare plan that documented the client and counselor's signature, specifically record #7.
Client #7 was admitted into inpatient treatment on March 24, 2012 and discharged on April 7, 2012. An aftercare plan was documented in the client #7's record however it was undated and unsigned by both the counselor and client.
The findings were confirmed by the Clinical Supervisor and Campus Director during the exit interview.
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Plan of Correction
The clinical supervisor will review documents for required signatures during weekly supervision sessions. Additionally, two closed charts per counselor per month will be audited for counselor and client signature compliance. The clinical supervisor will re-educate the clinician(s) regarding any noncompliance issue pertaining to case management and licensure guidelines during the time of supervision. This POC will take effect immediately. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on the review of inpatient client records and the facility's policies and procedures, the facility failed to document follow-ups in accordance with the facility's policies and procedures.
The findings include:
The facility's policy regarding follow-ups states:
If a referral is made, with the client's consent, the provider is contacted within 7 business days following the patient's scheduled aftercare appointment.
If no referral is made (including AMA clients), a contact call will be attempted within 30 business days after discharge.
Three inpatient client records were reviewed on April 23, 2012 for documentation of follow-ups. The facility failed to document follow-ups in accordance with the facility's policy in two out of three inpatient client records, specifically client records # 5 and 7.
Client #5 was admitted into inpatient treatment on January 29, 2012 and discharged on February 16, 2012. There was no referral made for client #5. The follow-up was due by March 16, 2012. As of the date of inspection, there was no documentation of a follow up for client #5.
Client #7 was admitted on March 24, 2012 and discharged on April 7, 2012. The client was referred on April 10, 2012. The follow-up was due by April 17, 2012. As of the date of inspection, there was no documentation of a follow up for client #7.
The findings were confirmed with the clinical supervisor and facility director at the exit interview.
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Plan of Correction
Effective immediately the clinical supervisor will monitor completion of follow-up documentation during weekly supervision sessions. Two closed charts per counselor per month will be audited for compliance regarding follow-up calls. Follow up calls will be made by the counselor and/or administrative assistant. The clinical supervisor will ensure compliance with the follow up calls.
Patient #5 and patient #7 were called and the follow-ups were completed.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of outpatient client records and the facility's policies and procedures, the facility failed to document treatment plans in accordance with the facility's policies and procedures.
The findings include:
In reference to the comprehensive treatment plan for outpatient clients, the project ' s policy states:
The comprehensive treatment plan is to be completed within 14 days of admission for intensive outpatient clients and within 21 days of admission for outpatient clients.
Eight outpatient client records were reviewed for comprehensive treatment plans on April 23, 2012. Three out of eight outpatient client records lacked a treatment plan that was documented within 14 or 21 days, specifically records #15, 16, and 17.
Client #15 was admitted into outpatient treatment on December 7, 2011 and discharged on February 8, 2012. The comprehensive treatment plan was due by December 28, 2011; however it had not been documented until January 9, 2012.
Client #16 was admitted into intensive outpatient treatment on December 14, 2011 and discharged on February 9, 2012. The comprehensive treatment plan was due by December 28, 2012; however it had not been documented until January 4, 2012.
Client #17 was admitted into intensive outpatient treatment on October 26, 2011 and discharged on February 23, 2012. The comprehensive treatment plan was due by November 9, 2011; however it had not been documented until December 15, 2011.
The findings were confirmed by the Clinical Supervisor during the exit interview.
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Plan of Correction
Clinical Supervisor will track the completion of the comprehensive treatment plan for the outpatient patients with the assigned clinician thru regular supervision and chart reviews. Clinical Supervisor will then address any non-compliance related to the comprehensive treatment plan time frames as it pertains to policy and licensure guidelines with the clinician in supervision sessions. This POC is effective immediately. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of staff training records, the facility failed to ensure clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision.
The findings include:
On April 4, 2012 one personnel record was reviewed for the position of clinical supervisor. Employee # 3 was hired at the project on May 12, 2008 and promoted to a clinical supervisor on August 7, 2011. After a review of employee #3's resume, it was found they had less than two years experience as supervisor in a clinical setting. Employee #3's training record did not have documentation of a core curriculum in clinical supervision.
These finding were confirmed with the clinical supervisor, campus director, and facility director prior to and during the exit interview.
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Plan of Correction
The clinical supervisor completed the Supervisor Core Curriculum training on June 15, 2012. Effective immediately and ongoing, the clinical supervisor will review clinical promotions with the Quality Improvement Department prior to promotion to ensure this situation does not occur again. |