INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on March 7, 2023 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide close supervision by a trained counselor or clinical supervisor for the first 6 months of employment.
Employee #6 was hired on March 30, 2021 and was still employed at the time of the inspection. He had no documentation of direct and close supervision, which is required for a person with a bachelor's degree.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility director will review 704.9(c) with the clinical supervisor so there is an understanding of supervision requirements.
The Quality Director has updated the Supervision Documentation form to include clear documentation of close supervision or direct observation (co-facilitated or in-person) and the context of each form of supervision (group, individual, screening, intake, staff meeting, treatment team, training and case review).
The Quality Director has distributed the new Supervision Documentation form to all clinical supervisors to be implemented asap.
HR will review employee records on a quarterly basis to ensure compliance with required supervision periods.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for facility directors.
Employee #2 was hired as a facility director on February 3, 2019 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2022 through December 31, 2022. Employee # 2's record only documented 10:48 hours of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility will assign a staff member to monitor training hours on site. The new Training Coordinator will keep track of all trainings completed by staff at the facility. A binder will be kept at the facility containing all training certificates with a tracker to monitor for hours.
The Training Coordinator will ensure all training certificates and evaluations are sent to the Quality Director. When staff are running low on training hours, the Quality Director will alert the staff's supervisor. The staff's supervisor will meet with the staff member and review training options to ensure compliance with 704.11(c)(3) & (4).
Quality Director will audit training hours on a quarterly basis to ensure compliance. Quality Director will send compliance reports to the Regional Program Director.
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705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection on March 7, 2023, the facility failed to ensure cold food was at or below 40F. The facility did not have a mechanism to ensure the temperature of cold food was at or below 40F.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Food Service Manager will purchase and install a thermometer for the refrigerator.
Facility walk-throughs will be conducted at least once per shift, one time per month to monitor safety and compliance. Facility walk-through sheets will be submitted to the Quality Director on a quarterly basis to monitor for compliance.
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on the review of inpatient non-hospital short term detoxification patient records, the facility failed to document in the patient's record determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment and the basis for the determination of current dependency and evidence of a 1 year history of addiction in four out of seven records reviewed.
Patient #1was admitted on March 2, 2023 and was still active at the time of the inspection.
Patient #2 was admitted on March 4, 2023 and was still active at the time of the inspection.
Patient #3 was admitted on March 2, 2023 and was still active at the time of the inspection.
Patient #4 was admitted on December 28, 2022 and discharged on January 3, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The physician will complete the Opiate Dependency Criteria Checklist indicating whether or not the client is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least one year prior to admission for maintenance treatment. This will be completed for all clients entering the treatment program.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
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