INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 24 & 25, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run Inc., 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 and a plan of correction is due on May 22, 2008.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based upon a review of the staffing forms and a self report by the facility on April 8 & 24, 2008, the facility failed to ensure that 28 of 139 staff persons required to receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum completed that training within the required time frames. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
Employees #12, 21, 24, 32, 33, 37, 39, 43, 44, 45, 53, 57, 58, 59, 60, 61, 62, 63, 68, 69, 70 & 71 had not completed the HIV/AIDS and the TB/STD training.
Employees #34 & 56 had not completed the TB/STD training.
Employees #14 , 35, 47 & 55 had not completed the HIV/AIDS training.
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Plan of Correction
All staff identified during the survey as having not completed HIV/AIDS and TB/STD training have been scheduled to attend the relevant trainings, which are scheduled to occur on May 29, 2008, and June 3, 2008. As the White Deer Run/CRC electronic education management system (Essential Learning) identifies staff training requirements for both HIV/AIDS and TB/STD, required training will be scheduled and fulfilled in a timely fashion. Clinical supervisors and department heads will be instructed by the senior leadership at White Deer Run, Allenwood and Williamsport, to remind staff of required trainings during the time of annual training plan development in January of each year. |
705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based upon observation during a physical plant tour on April 23 & 24, 2008, the facility failed to provide a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet for building #9.
The exits for the second floor of building #9 are separated by a distance of less than 15 feet (approximately 8 1/2 feet).
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Plan of Correction
White Deer Run is requesting an exception to this standard. Information is being forwarded to the Department of Health regarding our request. If the exception is not granted White Deer Run will provide a second exit at a minimum of 15 feet as per regulatory standards by 10/30/08. The reason for the extended period of time to correct the exiting issues is due to the need to submit plans for approval and to secure any required permits for the construction of the second exit.
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705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based upon observation during a physical plant tour on April 23 & 24, 2008, the facility failed to maintain each ramp, interior stairway and/or outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
The following stairs lacked well-secured handrails:
1. Building #2 basement stairs
2. The food Storage area basement stairs building 8
3. The stairs outside of the gymnasium.
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Plan of Correction
The railings required for both the storage area on the basement stairs in Building #8, and the stairs outside of the gymnasium/activities building, have been ordered by the contractor who will install them. The railings will be installed by August 1, 2008. The prolonged period before installation is due to the need for these railings to be fabricated and anchored into cement.
Well-secured hand rails will be placed at the basement stairs of building #2 by August 1, 2008. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based upon a review of facility policy and an interview with the nursing supervisor on April, 25, 2008, the facility does not conduct a psychosocial evaluation for clients that are only participating in the detox portion of treatment. The facility did not document psychosocial evaluations in the detoxification only client records.
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Plan of Correction
As a result of a citation in 2007, related to the evaluation section of the nursing assessments lacking adequate depth in evaluating patients, a decision was made to use the addendum on which to provide an evaluation for patients who are admitted for only detoxification. Counselors in the Diagnostic Observation Verification and Evaluation Unit (DOVE) are required to complete an evaluation on "detoxification only" patients as part of the "psychosocial addendum" to the nursing assessment. This is obviously an area in which training and evaluation is needed. All clinical staff in the DOVE unit will complete psychosocial assessment training (4 hours), with the Clinical Director or his designee by June 15, 2008. The Medical Records Director, or her designee, will review all the "detox only" charts, post discharge to assess compliance with a psychosocial assessment being entered into the patient record. The Clinical Care Committee will review 25% of "detox only" charts to assess the quality of the evaluations.
These two evaluative processes will continue over the following six months with follow-up trainings and supervision provided as necessary by the Clinical Director or his designee.
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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 upon a review of client records on April 24 and 25, 2008, the facility failed to ensure that a follow-up was conducted in accordance with the standards and facility policy of seven days for clients that are referred elsewhere after being discharged. Only one of the client records in the sample, client record #8, was required to have follow up documentation, but the follow up was not conducted until more than seven days from the date of discharge.
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Plan of Correction
The patient chart, which was identified (#8), actually had a note reflecting that follow up was completed on the eighth day. The Continuing Care Coordinator has been counseled about the requirement that follow-up to be completed within seven days of discharge. In the Clinical Care review process, 10% of records are reviewed to assess timeliness and quality of reporting on a variety of areas. An evaluation of patient follow-up for both timeliness and detail will be included in this review process. For any case in which the criteria in the licensing standards related to follow-up is not followed, the Clinical Director will be notified by the Director of Medical Records, and supervision and/or an employee improvement plan will be completed by the Clinical Director. |