INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 2, 2008 and May 5, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Perspectives 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 and a plan of correction is due on May 30, 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 personnel records and a self report by the facility, the facility failed to ensure that three of thirty-eight staff persons reviewed received 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 within the established time frames.
Two out of thirty-eight staff persons reviewed failed to complete the required minimum 4 hours of training for tuberculosis, sexually transmitted diseases and other health related topics within the established time frames, specifically staff members #6 & 8.
Three out of thirty-eight staff persons reviewed failed to complete the required minimum 6 hours of training for HIV/AIDS within the established time frames, specifically #6, 7 & 8.
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Plan of Correction
Campus Director will review staff roster for all non compliant staff. All non compliant staff will attend HIV/AIDS and TB/STD training on 6-17-08 and 6-18-08 at Lancaster WDR.
Campus Director will track staff roster for compliance each quarter via the Essential Learning Program. The Essesential Learning Program provides warning prompts to the employee, their supervisor, and the Campus Director when HIV/AIDS and TB/STD training is due and when it would be overdue.
In addition, Staff Development and Training along with New Perspectives will schedule and provide HIV/AIDS and TB/STD classes throughout the year. |
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 upon a review of staffing schedules and CPR/First Aid certifications on May 5, 2008, the facility failed to ensure that at least one person trained in these skills was onsite during the project's hours of operation on the following days for the hours as listed below:
The facility lacked CPR coverage for the detoxification unit on the following dates during the following hours:
March 30, 2008, 12:00 p.m. - 3:56 p.m.
April 5, 2008 12:00 a.m. - 4:00 a.m. and 8:00 a.m. -8:00 p.m.
April 6, 2008 5:42 p.m. - 6:00 p.m.
April 12, 2008 12:00 p.m. - 4:00 p.m.
April 13, 2008 8:00 a.m. - 4:00 p.m.
April 19, 2008 4:30 p.m. - 6:00 p.m.
April 20, 2008 8:00 a.m. - 6:00 p.m.
April 26, 2008 2:37 p.m. - 4:00 p.m.
The facility lacked CPR coverage for the remainder of the campus either due to there being nobody on site with CPR and/or First Aid certification or due to the nurse not being able to leave the detoxification unit.
March 30, 2008 from 12:00 p.m. - 3:56 p.m. and 8:19 p.m.-l 12:00 a.m.
April 1, 2008 8:22 p.m.-12:00 a.m.
April 2, 2008 8:15 p.m. - 12:00 a.m.
April 3, 2008 8:30 p.m. - 12:00 a.m.
April 4, 2008 6:16 p.m. - 12:00 a.m.
April 5, 2008 from 12:00 a.m. Saturday until 12:00 a.m. Sunday
April 6, 2008 5:42 p.m. - 10:00 p.m.
April 7, 2008 8:51 p.m. - 10:00 p.m.
April 8, 2008 9:00 p.m. - 10:00 p.m.
April 9, 2008 7:21 p.m. - 10:00 p.m.
April 10, 2008 8:34 p.m. - 10:00 p.m.
April 11, 2008 7:53 p.m. - 12:00 a.m.
April 12, 2008 12:00 a.m. - 5:00 a.m. and 12:00 p.m. - 12:00 a.m. April 13 2008.
April 13, 2008 8:00 a.m. - 4:00 p.m. and 4:30 p.m. - 10:00 p.m.
April 14, 2008 4:30 p.m. - 8:29 p.m.
April 15, 2008 4:30 p.m. - 7:08 p.m.
April 16, 2008 4:30 p.m. - 7:12 p.m.
April 17, 2008 8:53 p.m. - 10:00 p.m.
April 18, 2008 8:46 p.m. - 12:00 a.m.
April 19, 2008 4:30 p.m. - 10:00 p.m.
April 20, 2008 8:00 a.m. - 12:00 a.m.
April 21, 2008 8:03 p.m. - 10:00 p.m.
April 22, 2008 9:24 p.m. - 10:00 p.m. .
April 23, 2008 4:30 p.m. - 4:45 p.m.
April 24, 2008 7:28 p.m. - 12:00 a.m.
April 25, 2008 4:30 p.m. - 12:00 a.m.
April 26, 2008 12:00 a.m. - 5:00 a.m., 2:37 p.m. - 4:00 p.m. and 4:30 p.m. - 12:00 a.m.
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Plan of Correction
As of 5-5-08, Campus Director reviewed the staff roster for staff that had current CPR/1st Aid certification and reviewed and revised staff schedule to ensure that CPR/1st Aid coverage was provided and will be provided until 6-15-08 when all staff have received CPR/1st Aid certification. Campus Director has reviewed staff roster for non compliant staff. All non compliant staff will receive CPR/1st Aid certification by 6-15-08.
Campus Director will track staff roster for compliance each quarter via the Essential Learning Program. The Essential Learning Program provides warning prompts to the employee, their supervisor, and the Campus Director when CPR/1st Aid certification is due and when it has become overdue.
In addition, Staff Development and Training along with New Perspectives will schedule and provide CPR/1st Aid certification classes throughout the year. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based upon a review of client records, the facility failed to document that they reviewed and updated the medical histories that were conducted in their inpatient unit or at other facilities within the organization in 2 of 6 records reviewed, specifically client records #7 & 8.
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Plan of Correction
Campus Director will review policies and procedures of Intake and Admission, particularly the Medical History with staff in the next weekly outpatient counselors meeting on 6-3-08.
In addition, The Regional Clinical Supervisor will also review at a minimum 25% of all charts over the next 3 months for compliance. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based upon a review of client records, the facility failed to document that they reviewed and updated the drug and alcohol histories that were conducted in their inpatient unit or at other facilities within the organization in 2 of 6 records reviewed, specifically records #7 & 8.
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Plan of Correction
Campus Director will review policies and procedures of Intake and Admission particularly, the Drug and Alcohol histories in the next weekly outpatient counselors meeting on 6-3-08.
Regional Clinical Supervisor will also review a minimum of 25% of all charts over the next 3 months for compliance. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based upon a review of client records, the facility failed to document that they reviewed and updated the personal histories that were conducted in their inpatient unit or at other facilities within the organization in 2 of 6 records reviewed, specifically client records #7 & 8.
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Plan of Correction
Campus Director will review policies and procedures of Intake and Admission particularly, the Personal Histories in the next weekly outpatient counselors meeting on 6-3-08.
Regional Clinical Supervisor will also review a minimum of 25% of all charts over the next 3 months for compliance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based upon a review of client records, the facility failed to complete biopsychosocial evaluations within the facility timeframe in 3 of 6 client records reviewed.
The facility failed to document that they reviewed and updated the psychosocial evaluations that were conducted in their inpatient unit or at other facilities within the organization in 2 of 6 client records reviewed, specifically records #7 & 8.
Client record #10 had been admitted on 10/16/07 yet the psychosocial evaluation had not been completed until 12/10/07.
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Plan of Correction
Campus Director will review policies and procedures of Intake and Admission particularly, the Psychosocial Evaluation, in the next weekly outpatient counselors meeting on 6-3-08.
Regional Clinical Supervisor will also review at a minimum 25% of all charts over the next 3 months for compliance. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based upon a review of client records, the facility failed to develop individualized treatment plans within the facility time frames and/or based upon current documented histories and a psychosocial evaluation of the client in 4 of 6 client records reviewed.
The clinician failed to document in the treatment plans developed for 2 of 6 clients, #7 & 8, that they reviewed and updated the histories and psychosocial evaluations that were conducted during inpatient treatment or at other facilities within the organization.
The treatment plans documented in 3 of 6 client records had not been completed within the facility time frames. Client record #7 indicated that the client had been admitted on 3/6/08 and client record #11 indicated that the client had been admitted on 3/26/08, yet the treatment plans had not been signed and dated. Client record # 10 indicated that the client had been admitted on 10/16/07 and the treatment plan was not completed until 12/10/07.
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Plan of Correction
Campus Director will review policies and procedures of an individual treatment plan in the next weekly outpatient counselors meeting on 6-3-08.
Regional Clinical Supervisor will also review at a minimum 25% of all charts over the next 3 months for compliance. |
709.93(a)(11) LICENSURE Client records
709.93. 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 six client records, the facility failed to document a follow up attempt within the facility time frame in one of two client records reviewed where such documentation was required. Client record #9 indicated that the client was discharged on 12/18/07 with a referral and the follow-up had not been conducted until 2/20/08.
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Plan of Correction
Campus Director will review policies and procedures regarding completing follow up information in the next weekly outpatient counselor meeting on 6-3-08.
Regional Clinical Supervisor will also review a minimum of 25% of all charts over the next 3 months for compliance.
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