INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 31-May 1, 2012 by staff from the Division of Drug and Alcohol 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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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
Citation 0135
On April 27, 2012 the Project Director and the Quality Management Director revised the Governing Body policy which includes the time frame for completion of the annual report. On May 21, 2012 the Governing Body approved the policy revisions which state that the annual report will be made available to the general public upon completion of the financial audit for that calendar year. CRC's fiscal year is a calendar year and runs from January 1 through December 31. CRC Corporate offices will complete the 10-K and will file it with the SEC upon completion of the calendar year. The Executive Director will create the annual report after the 10-K is filed. The Governing Body will approve the annual report upon its completion. Upon approval the public will be made aware it is available for review. The Executive Director is responsible for assuring that the Annual Report is completed within the designated time frame. The Quality Management Director will monitor this process via communication with the Executive Director in weekly conference calls as well as through weekly Division conference calls. The Quality Management Director has distributed the aforementioned policy change to all administrators and key staff.
Corrective Action Date is June 30, 2012.
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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.
Corrective Action Date is May 22, 2012.
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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 30, 2012 for documentation of follow-ups. The facility failed to document a follow-up in accordance with the facility's policy in one out of three inpatient client records, specifically client record # 9.
Client #9 was admitted on December 19, 2011 and discharged on January 3, 2012. The client was not referred. The follow-up was due to be documented by February 3, 2012. As of the date of inspection, there was no documentation of a follow up for client # 9.
The findings were confirmed with the clinical supervisor and facility director at the exit interview.
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Plan of Correction
On May 2nd, 2012, following our licenisng the office manager completed the follow up on Client #9. On May 7th, 2012, Campus Director created a tracking system to insure all Follow-Up documentation is completed within the allotted time frames as stated in the policy. The tracking system consists of a form that includes; patient name, date of discharge, discharge status and follow-up due date. This system will be managed by the Office Manager on a daily basis by reviewing the previous day's discharges and documenting when the Follow Up form was received and finalized. Ongoing compliance will be monitored by the Campus Director/Facility Director. |