INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on February 8, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, White Deer Run Inc., 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of six personnel records, the facility failed to document monthly meetings with the clinical supervisor and their supervisor discussing the clinical supervisors duties and performances for the first 6 months of employment in that position.
Employee #3, who was hired as a clinical supervisor on August 14, 2023 and was still employed in that position at the time of the inspection did not have documentation of supervision occurring monthly.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility will document monthly meetings with the new clinical supervisor and their supervisor discussing supervisory duties.
Campus director will meet with new supervisor at least monthly to review supervisory duties.
Supervisions will be documented in a binder available for Risk/Quality to review monthly.
Facility will continue these until supervisor has at least 6 months.
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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 six personnel records, the facility failed to hire one counselor that has required one year of clinical experience and a qualifying degree.
Employee #6 was hired as a counselor according to the Staffing Requirements Facility Summary Report on September 5, 2023 and was still current in that position. Employee #6 had a qualifying bachelor ' s degree but did not have the required one year of clinical experience.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will follow counselor requirements from DDAP for hiring and for supervision.
Facility will be sending a letter of request for the Act 66 flexibility in the hiring regulations.
Director will review employee resumes prior to hiring to determine if they meet requirements for a Counselor or CA and proceed with the correct form of supervision.
Ongoing HR and Director will determine if candidate is hired and the requirements they will need. |
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 personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level in five out of six employee records reviewed.
Employee#2 was hired on September 5, 2023 as a facility director and was still in the position as of the date of the inspection. The facility failed to submit documentation of an individual training plan.
Employee #3 was hired on August 14, 2023 as a clinical supervisor and was still in the position as of the date of the inspection. The facility failed to submit documentation of an individual training plan.
Employee #4 was hired on August 21, 2023 as a counselor and was still in the position as of the date of the inspection. The facility failed to submit documentation of an individual training plan.
Employee #5 was hired on December 18, 2023, 2023 as a counselor and was still in the position as of the date of the inspection. The facility failed to submit documentation of an individual training plan.
Employee #6 was hired on September 5, 2023 as a counselor assistant and then promoted to a counselor on January 5, 2024 and was still in the position as of the date of the inspection. The facility failed to submit documentation of an individual training plan.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility will ensure all annual training plans are completed and available for the pre submission process.
Annually HR will collect from all managers the training plans for the upcoming year.
Directory will keep a copy of all training plans on site.
HR will review all training plans to ensure they are completed and will be responsible to submit these on pre submission. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure five applicable employees received the required training in the use of the fire extinguishers upon employment.
Employee #2 was hired on September 5, 2023 for the position of facility director and was still employed at the time of the inspection. There is no documentation that the employee was trained in the use of fire extinguishers.
Employee #3 was hired on August 14, 2023 as a counselor and was still employed at the time of the inspection. There is no documentation that the employee was trained in the use of fire extinguishers.
Employee #4 was hired on August 21, 2023 as a counselor and was still employed at the time of the inspection. There is no documentation that the employee was trained in the use of fire extinguishers.
Employee #5 was hired on December 18, 2023 and was still employed at the time of the inspection. There is no documentation that the employee was trained in the use of fire extinguishers.
Employee #6 was hired on September 5, 2023 as a counselor assistant and then promoted to a counselor on January 5, 2024 and is still employed at the time of the inspection. There is no documentation that the employee was trained in the use of fire extinguishers.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure that all employees will be trained in fire safety on their first day of employment.
HR and Quality/Risk will make sure all new employees sign off on their fire safety training on their first day of employment.
Employee number 4 and number 6 have received fire safety training and have signed off on the training.
HR will continue to monitor all new hire paperwork monthly to ensure that all employees are receiving this training upon starting.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure five applicable employees received the required training to perform assigned tasks during emergencies.
Employee #2 was hired on September 5, 2023 for the position of facility director and was still employed at the time of the inspection. There is no documentation that the employee was trained to perform assigned tasks during emergencies.
Employee #3 was hired on August 14, 2023 as a counselor and was still employed at the time of the inspection. There is no documentation that the employee was trained to perform assigned tasks during emergencies.
Employee #4 was hired on August 21, 2023 as a counselor and was still employed at the time of the inspection. There is no documentation that the employee was trained to perform assigned tasks during emergencies.
Employee #5 was hired on December 18, 2023 and was still employed at the time of the inspection. There is no documentation that the employee was trained to perform assigned tasks during emergencies.
Employee #6 was hired on September 5, 2023 as a counselor assistant and then promoted to a counselor on January 5, 2024 and is still employed at the time of the inspection. There is no documentation that the employee was trained to perform assigned tasks during emergencies.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure that all employees will receive emergency training through the Quality Risk Manager
HR will make sure all employees receive their emergency training along with their new hire packets that managers sign of on
This will be monitored by HR prior to the employees first shift.
Ongoing: HR will hold on to all employee's verification that they have completed this training.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility ' s fire drills logs from April 2023 through January 2024, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There was no documentation that an overnight fire drill occurred.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility will ensure fire drills will be completed during sleeping hours at least every 6 months.
Director will meet with the Behavioral Health Associates and go over the procedure for having at least 1 overnight fire drill per six months.
Ongoing: Director will review fire drill logs with BHA Supervisor quarterly. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility ' s fire drills logs from April 2023 through January 2024, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill for the months of April 2023 through January 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure that a fire alarm or smoke detector was set off for the fire drills.
Director will meet with the Behavioral Health Associates and go over the procedure by 3/22/24 during all staff meeting.
Fire drills will continue to be held monthly.
Ongoing: Director and Behavioral Health Supervisor will monitor fire drill logs monthly. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of ten records reviewed.
Client #7 was admitted to the detox level of care on January 12, 2024 and discharged on January 18, 2024 and stepped down to residential level of care on January 18, 2024 and discharged on February 5, 2024. There was no informed and voluntary consent to release information form for a drug and alcohol provider; however, there was documentation that the facility was contacted as part of aftercare planning.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Quality and Risk manager will conduct a training on the consents at the facility by March 29 2024 where employees will be trained on the correct procedures for obtaining consent. Clinical Director and nurse manager will pull five random charts weekly over the next eight weeks to review and document consents are being completed correctly. Since the client was discharged no further action can be completed with their consents.
Ongoing: consents will be reviewed by Clinical Director on monthly chart reviews and in supervisions.
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709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of administrative information, client records, personnel records, and the facility policy manual, the facility failed to develop a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
The following materials were requested however the facility was unable to provide them during the licensing process:
The Staffing Requirement Facility Summary Report (SRFSR), training documentations, and individual training plans.
This finding was reviewed with the facility during the licensing process.
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Plan of Correction
The facility will complete pre-submission documentation including staffing summary report, training plans, work performances and data collection form prior to the inspection.
Risk /Quality Manager has received technical support training on 2/28/24 on the pre=submission process
Risk and quality manager along with HR will provide training to all leadership on the proper completion of staffing grids as well as submission of documentation by 3/29/24.
HR and Risk management will review staffing requirement summary report prior to submitting to DDAP
Ongoing: Monthly HR and Risk will review personal records and update for new hires
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to provide a treatment and rehabilitation plan that included the type and frequency of services in two of six records reviewed.
Client #4 was admitted on January 29, 2024 and was a still active at the time of the inspection. A comprehensive treatment plan was developed on February 5, 2024 that did not include the type and frequency of services.
Client #10 was admitted on July 12, 2023 and discharged on August 24, 2023. A comprehensive treatment plan was developed on July 16, 2023, that did not include the type and frequency of services.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility will complete treatment plans that include type and frequency on all rehab clients. Director will review with all staff the procedure for adding type and frequency in our medical record treatment plans in the March All Staff meeting.
Director will review 5 random charts weekly over the next eight weeks to ensure treatment plans address type and frequency in treatment plans.
Ongoing, chart audits will be conducted for type and frequency in the treatment plans and will be reviewed in supervisions.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the facility ' s policy of every 14 days in two out of four applicable records reviewed.
Client #5 was admitted on January 17, 2024 and still active at the time of the inspection. A treatment plan was completed on January 22, 2024 and the next update was due no later than February 5, 2024; however, there is no documentation that one was completed.
Client #10 was admitted on July 12, 2023 and was discharged on August 24, 2023. A treatment plan was completed on July 16, 2023 and the next update was due no later than July 30, 2023; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure treatment plan updates are completed every 14 days. Clinical Supervisor will provide a training to the counselors by March 29, 2024, reviewing the policy on treatment plan updates.
For the next eight weeks Clinical Supervisor will pull 5 charts and review for treatment plan updates.
For client number 5 a treatment plan update was completed. The client that is no longer here cannot be updated.
Ongoing Clinical Director will review treatment plan updates during supervision and monthly chart audits. |
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 client records, the facility failed to provide a complete client record, which is to include a discharge summary in two out of three records reviewed.
Client #9 was admitted on October 17, 2023 and was discharged on January 10, 2024. There was no documentation that a discharge summary was completed.
Client #10 was admitted on July 12, 2023 and was discharged on August 24, 2023. There was no documentation that a discharge summary was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that a discharge summary is completed for each client.
Director will provide training on writing discharge summaries following the regulations by D-DAP.
Over the next 8 weeks director will pull 5 random discharges to ensure discharges summary are being done correctly and timely.
Ongoing when flow up is completed director will check charts to ensure that discharge summary is completed. |