INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24, 2021 and March 26, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Perspective 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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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 the physical plant inspection conducted on March 26, 2021, the facility failed to ensure that hot water temperatures did not exceed 120 degrees Fahrenheit.
When tested with a thermometer, the hot water in the adjoining bathroom for room numbers three and four within the female dormitory tested at 128.4 degrees Fahrenheit.
When tested with a thermometer, the hot water in the unisex bathroom in the cafeteria tested at 128.3 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility Safety Officer has turned down the water temperature in the female dormitory and in the unisex bathroom in the cafeteria so it does not exceed 120F.
Water temperatures will be monitored on a daily basis through monthly safety assessment.
Quality Director will monitor for compliance on a quarterly basis.
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705.7 (b) (4) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
Based on the physical plant inspection conducted on March 26, 2021, the facility failed to ensure that storage areas for foods are free of food particles, dust and dirt.
The chest freezer in the cafeteria had unpackaged French toast laying among other packaged food items.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Dietary staff will ensure food particles, dust and dirt are not present in food storage areas by completing a daily inspection of the food service areas.
The Regional Dietary manager will monitor for compliance at least once per month at a minimum.
The unpackaged French toast has been removed from the chest freezer.
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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 the physical plant inspection conducted on March 26, 2021, the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
The emergency exit in the common area of the female dormitory was blocked with chairs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will review requirements of clear stairways, hallways and exits with all staff at the next all staff meeting by end of April, 2021.
Chairs have been removed from the emergency exit in the female dormitory.
Facility Safety Officer will monitor during monthly safety assessments.
Quality Director will monitor for compliance on a quarterly basis.
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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of fourteen client records reviewed.
Client #8 was admitted on December 31, 2020 and was discharged on January 11, 2021. There was documentation of communication between project staff and another treatment facility that took place on January 12, 2021; however, there was no proper consent to release information form signed by the client prior to disclosure.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
All staff responsible for completing consents (nursing, clinical, admissions and intake staff) will attend the DDAP Confidentiality training by June 1, 2021. Certificate of attendance will be maintained in each training file.
Quality Director will hold an in-service training to be attended by staff responsible for completing consents (nursing, clinical, admissions and intake staff) at least once per month on confidentiality and proper completion of consents beginning April 1, 2021.
Monthly chart audits will be completed by nursing, clinical, admissions and intake staff to monitor for compliance. Results of monthly chart audits will be shared with Facility Director and Quality Director.
Consent for client #8 is unable to be obtained due to client has discharged from treatment.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in two of fourteen client records reviewed.
Client #1 was admitted on March 13, 2021 and was a current client at the time of the inspection. A release of information form to the client ' s paramour, signed and dated by the client on March 23, 2021, did not document the specific information to be disclosed.
Client #7 was admitted on August 21, 2020 and was discharged on September 11, 2020. A release of information form to a probation agency, signed and dated by the client on August 21, 2020, did not document the specific information to be disclosed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
All staff responsible for completing consents (nursing, clinical, admissions and intake staff) will attend the DDAP Confidentiality training by June 1, 2021. Certificate of attendance will be maintained in each training file.
Quality Director will hold an in-service training to be attended by staff responsible for completing consents (nursing, clinical, admissions and intake staff) at least once per month on confidentiality and proper completion of consents beginning April 1, 2021.
Monthly chart audits will be completed by nursing, clinical, admissions and intake staff to monitor for compliance. Results of monthly chart audits will be shared with Facility Director and Quality Director.
Consent for client #7 is unable to be obtained due to client has discharged from treatment.
Consent was obtained for Client #1.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one of fourteen client records reviewed.
Client #1 was admitted on March 13, 2021 and was an active client at the time of the inspection. A release of information form to a paramour, signed and dated by the client on March 23, 2021 did not include the purpose of disclosure.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
All staff responsible for completing consents (nursing, clinical, admissions and intake staff) will attend the DDAP Confidentiality training by June 1, 2021. Certificate of attendance will be maintained in each training file.
Quality Director will hold an in-service training to be attended by staff responsible for completing consents (nursing, clinical, admissions and intake staff) at least once per month on confidentiality and proper completion of consents beginning April 1, 2021.
Monthly chart audits will be completed by nursing, clinical, admissions and intake staff to monitor for compliance. Results of monthly chart audits will be shared with Facility Director and Quality Director.
Consent was obtained for Client #1.
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