INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and inspection conducted for the approval to use a narcotic agent, specifically Buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on March 8, 2016 by staff from the Department of Drug and Alcohol Programs Licensure Division. 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and CPR/First Aid certification cards, the facility failed to ensure that a sufficient number of staff persons were trained in CPR/First Aid so that at least one person trained in these skills was onsite during the project's hours of operations.
The findings include:
All employee CPR/First Aid certification cards were reviewed on March 8, 2016. A three month work schedule was reviewed and showed several days where staff worked and there was no CPR coverage. The facility is open 24 hours Sunday through Saturday.
The following dates and times reflect a lack of CPR coverage:
12 AM to 8 AM shift
November: 1,7,8,14,15,21,22,28,29
December: 1,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31
January: 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,25,26,27,28,29,30
8 AM to 4 PM shift
November: 1,2,4,6,7,8,9,11,12,13,14,15,16,17,18,19,20,21,23,24,25,26,27,28,30
December: 2,3,4,7,8,9,10,11,13,14,15,16,17,18,21,22,23,25,26,27,28,29,30,31
January: 1,2,9,13,20,25,29,
4 PM to 12 AM Shift
November 1,4,5,6,9,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29
December 2,3,5,6,7,12,13,14,19,20,21,26,27
January 1,2,3,4,9,10,11,13,16,17,18,23,24,25,28,29,30
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Program Director will meet with Program Managers and review the standard for having all shifts covered by CPR/First Aid certified employees. Nurse Manager will track all expirations of CPR cards to ensure employees are current. The Region will ensure CPR/First Aid training is offered on a regular basis to employees. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to ensure the facility grounds were clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
The findings include:
The physical plant inspection occurred on March 8, 2016 at approximately 10:30 am. The second floor landing of the fire escape was obstructed by several layers of cardboard. This presented a fall hazard.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Technician Supervisor will ensure fire escape remains free from debris by way of including fire escape in the clinical technicians walk through, every half hour, while they are doing their physical plant checks. Technician Supervisor will review these sheets weekly and reinforce that this is being completed in ongoing technician meetings monthly. |
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, the facility failed to document the instruction of staff in the use of a fire extinguisher upon staff employment for one of four personnel records reviewed.
The findings include:
Four personnel records were reviewed on March 8, 2016. The facility failed to document that the fire extinguisher training was completed upon employment for employee #4.
Employee # 4 was hired on November 30, 2015. Fire extinguisher training was due to be completed no later than December 7, 2015. The facility did not document the completion of fire extinguisher training until February 2, 2016.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Technician Supervisor will ensure all new hire employees will be instructed in fire safety, including the use of fire extinguishers, within their first three (3)days of emplyment. Certificate of Training will be filed in employee HR file. |
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, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one of four personnel records reviewed.
The findings include:
Four personnel records were reviewed on March 8, 2016. The facility failed to document that the emergency training was completed for employee, # 4.
Employee # 4 was hired on November 30, 2015. Emergency training was due to be completed no later than December 7, 2015. The facility did not document the completion of emergency training until February 2, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Technician Supervisor will ensure all new hire employees recieve the Fire and Safety Training, including what to do in an emergency situation, within their first three (3) days of employment. Certificate of Training will be filed in employee HR file. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill logs, the facility failed to conduct unannounced fire drills at least once per month as required by regulation.
The findings include:
The fire drill logs were reviewed on March 8, 2016 from the date of the last inspection, March 2, 2015. Fire drills were required from the month of April 2015 until February 2016. There was no documentation of unannounced fire drills for the months of April 2015, June 2015, July 2015, August 2015, September 2015, November 2015, December 2015, and January 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Technician Supervisor has updated the facility Physical Plant and Fire Safety Manual to include monthly fire drill records. Technician Supervisor will train new technicians and ensure unannounced fire drills will be documented every month. Program Director will review the manual monthly over the next quarter,to confirm these are being completed. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in seven of ten client records.
The findings include:
Ten client records were reviewed on March 8, 2016 for informed and voluntary consent to release client information. The facility failed to obtain or document an informed and voluntary consent to release in client records # 1, 2, 3, 4, 7, 8 and 9.
Client #1 was admitted on February 21, 2016 and was still an active client at the time of inspection. A consent form dated 2/16/16 allowed for the release of the clients alcohol, drug, or substance abuse records, HIV testing and results, and mental health records to an insurance company. In addition, the facility failed to comply with 42 CFR as the consent only allowed the client to revoke their consent form in writing.
Client #2 was admitted on February 12, 2016 and was still an active client at the time of inspection. A consent form dated 2/5/16 allowed for the release of the clients alcohol, drug, or substance abuse records to probation. In addition the facility failed to comply with 42 CFR as the consent only allowed the client to revoke the consent form in writing.
Client #3 was admitted on February 20, 2016 and was still an active client at the time of inspection. The facility failed to comply with 42 CFR as the consent only allowed the client to revoke the consent form in writing.
Client #4 was admitted on February 19, 2016 and was still an active client at the time of inspection. The facility failed to comply with 42 CFR as the consent only allowed the client to revoke the consent form in writing.
Client #7 was admitted on March 4, 2016 and discharged on March 8, 2016. A consent form dated 3/4/16 allowed for the release of the clients alcohol, drug, or substance abuse records, HIV testing and results, and mental health records to an insurance company and government agency. In addition the facility failed to comply with 42 CFR as the consent only allowed the client to revoke the consent form in writing.
Client #8 was admitted on March 6, 2016 and was still an active client at the time of inspection. A consent form dated 3/6/16 allowed for the release of the clients alcohol, drug, or substance abuse records, HIV testing and results, and mental health records to an insurance company. In addition the facility failed to comply with 42 CFR as the consent only allowed the client to revoke the consent form in writing.
Client #9 was admitted on February 15, 2016 was still an active client at the time of inspection. The facility failed to comply with 42 CFR as the consent only allowed the client to revoke the consent form in writing.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nurse Manager provided a training 3/17/2016 on the proper documentation for the Release of Information on the consents. An additional line has been added to consents indicating the consent can be revoked verbally. All current clients resigned new consents as of 4/10/16. Nurse Manager will randomly check 5 charts per week for the next 8 weeks to ensure consents are correct. Quality Manager is working with corporate to make changes to the consent document which will permanently address the issue. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the project failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in three of nine client records reviewed.
The findings include:
Nine client records were reviewed for counseling services during the renewal inspection on March 8, 2016. The project failed to ensure that clients received counseling services according to the client's individual treatment and rehabilitation plan in client records # 2, 5, and 6.
Client # 2 was admitted to the facility on February 12, 2016 and was still an active client at the time of inspection. Client #2's record contained a treatment plan dated 2/15/16 that identified the counseling services to be provided as individual therapy twice per week and group therapy four times per week. The record did not contain documentation of any individual therapy sessions from 2/26/2016 - 3/7/2016.
Client # 5 was admitted to the facility on February 20, 2016 and was still an active client at the time of inspection. Client #5's record contained a treatment plan dated 2/23/16 that identified the counseling services to be provided as individual therapy once per week and group therapy four times per week. The record did not contain documentation of any individual therapy sessions for the week of 2/28/2016-3/06/2016.
Client # 6 was admitted to the facility on February 19, 2016 and was still an active client at the time of inspection. Client #6's record contained a treatment plan dated 2/24/16 that identified the counseling services to be provided as individual therapy once per week and group therapy four times per week. The record did not contain documentation of any individual therapy sessions for the week of 2/27/16-3/5/2016.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Clinical Supervisor provided training to counselors regarding the standards and documentaiton of individual sessions on 3/28/2016. Clinical Supervisor will check to make sure DAP Note, and Record of Service match what is indicated on the Client Treatment Plan. Minimum standard of one individual per week will be met.
Clinical Supervisor will monitor compliance through monthly chart reiews and supervisions. |