INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on April 21, 2022, 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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704.11(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 staff schedules and CPR certifications provided by the facility, the facility failed to ensure that at least one person with current CPR certification was onsite during the project ' s hours of operations. The following shifts did not have staff with current CPR certification:
3/6/22 - 7:00 a.m. - 11:00 a.m.
3/13/22 - 7:30 a.m. - 11:00 a.m.
3/20/22 - 7:30 a.m. - 3:00 p.m.
3/27/22 - 7:30 a.m. - 12:00 p.m.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that at least one person with current CPR certification will be onsite during the project's hours of operations. Nurse Manager has completed her CPR training and has implemented electronic CPR training system for all staff that tracks who is due and who needs to complete. All shifts now have at least one person who is current with their CPR certification. Risk Manager will review the electronically generated list monthly to ensure facility remains in compliance. This was completed by May 1 2022. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one applicable record.
Employee # 4 was hired as a counselor on November 11, 2019 and has remained in that position since. The facility's training year that was reviewed was from January 2021 through December 2021. Employee #4's personnel record only documented 24.5 hours of training for the period reviewed.
This is a repeat citation from the July 16, 2021 annual licensure renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each counselor shall complete at least 25 clock hours of training annually in areas related to their position and deemed appropriate by the training hours required by counselors according to704.11(f)(2) Licensure. Compliance will be monitored by our Clinical Supervisor. A monthly score card of all staffs current training hours will be monitored and checked against requirements.
Employee # 4 is no longer working at the center. Continued monthly tracking of the hours will be sent to Clinical Supervisor who will review in supervisions. In compliance as of 5/1/2022.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on April 21, 2022, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as one trash receptacle outside each of the buildings were so full, the lid was unable to close, and the receptacle was uncovered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The facility will continue to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week. The facility Director contacted the waste management company of Penn Waste and informed them facility needs regular 2x a week removal of trash. Director will be notified if the garbage is not picked up so that the waste management company will be contacted same day. Completion date May 1, 2022.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection on April 21, 2022, the facility failed ensure that there was proper ventilation by either an exhaust fan or a window in either of the two second floor bathrooms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The residential facility purchased new exhaust fans for ventilation in the toilet and wash rooms on the second floor. Fans will be installed and operational by May 18 2022. Campus director will ensure the work is completed. Bathrooms will be inspected daily by BHA staff and weekly by maintenance coordinator. Any issues will be reported same day to the campus director so that they can be addressed. Fan installs will be completed by May 18,2022. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection on April 21, 2022, the facility failed to maintain each bathroom in a functional manner at all times. The second floor bathroom which was the third door on the right hand side, was not operable when tested several times throughout the day.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will maintain each bathroom in a functional manner at all times. The second floor bathroom toilet third door on the left hand side, had flushing mechanism replaced. Bathrooms will be inspected daily by BHA supervisor and weekly by maintenance coordinator. Any issues with their operations be reported to Program director. Maintenance coordinator will be scheduled to make repair. Program Director will monitor that the work is complete. Corrected by May 1 2022. |
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 fire drill logs from July 2021 through February 2022, the facility failed to ensure that each fire drill log contained the exit route used, as the August 31, 2021 log was missing this information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Quality and Risk Manager retrained staff including the Safety Officer on how to 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. Safety officer will ensure that each fire drill log contains the exit rout. Fire drill logs will be reviewed by the Risk manager every month for the next 90 days and then quarterly thereafter. This was completed May 6 2022. |
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 a review of fourteen records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in seven records reviewed. Additionally, the facility failed to keep disclosures of client information within the limits established in the signed informed and voluntary consent to release information form by the client in one record reviewed.
Client #1 was admitted to the Detox activity on April 15, 2022 and was active in the Rehabilitation Activity at the time of the inspection. The record contained documentation that personally identifying information was released to the Department of Human Services on April 15, 2022, with no consent to release information form signed by the client.
Client #2 was admitted to the Detox activity on March 5, 2022 and was discharged on March 8, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on March 5, 2022, with no consent to release information form signed by the client.
Client #3 was admitted to the Detox activity on April 3, 2022 and was discharged on April 7, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on April 3, 2022, with no consent to release information form signed by the client.
Client #4 was admitted to the Detox activity on February 14, 2022 and discharged on February 22, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on February 14, 2022, with no consent to release information form signed by the client.
Client #8 was admitted to the Rehabilitation activity on September 1, 2021 and discharged on September 30, 2021. The record contained documentation that personally identifying information was released to the Department of Human Services on September 1, 2021, with no consent to release information form signed by the client.
Client #9 was admitted on March 31, 2022 and was active at the time of the inspection. The record contained documentation of a letter sent to a judge on April 11, 2022, which disclosed the nature of the project; however, the client signed consent to release information form completed on April 11, 2022 did not allow for the disclosure of that information.
Client #13 was admitted to the Rehabilitation activity on March 8, 2022 and was active at the time of the inspection. The record contained documentation that personally identifying information was released to the Department of Human Services on March 8, 2022, with no consent to release information form signed by the client.
Client #14 was admitted to the Rehabilitation activity on April 7, 2022 and was active at the time of the inspection. The record contained documentation that personally identifying information was released to the Department of Human Services on April 7, 2022, with no consent to release information form signed by the client.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A newly developed consent for DHS will be completed for each admission to verify identity. Quality and Risk Manger provided information and training to staff in center on obtain consent from the Department of Human Services for every client admitted prior to using ePROMISE portal for verification purposes. This item will be monitored by Program Director in our monthly chart audits. This was completed by May 6, 2022. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of fourteen records, the certified registered nurse practitioner (CRNP) did not date verbal orders in one record reviewed, making it impossible to determine if they were done within the regulatory timeframe.
Client #10 was admitted to the inpatient rehabilitation activity on January 18, 2022 and was active at the time of the inspection. Verbal orders on February 3, 2022, March 2, 2022, April 6, 2022, and April 8, 2022 were not dated when signed by the CRNP.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility Director will reiterate and reinform CRNP to properly date, time, and sign off on all orders timely. Nursing Department will also ensure that order checks are done within 24 hours of verbal or written order and signed off on to ensure this is being completed. Nurse manager will monitor this is being completed on their monthly chart audits. Nurse manager will notify Program Director if these are done incorrectly. This was completed by May 6 2022 |
709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on a review of fourteen client records, the facility failed to record medication errors in one client record reviewed.
Client #4 was admitted to the detox activity on February 14, 2022 and discharged on February 22, 2022. The record contained documentation that the client was administered a medication, which was noted to be an allergy in the client ' s record, on two occasions, and neither incident was noted in the client record as an error.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nurse manager provided training to nursing department in her monthly nurse meeting around med errors. Nurse manager will maintain proper record of medication errors that have occurred and immediately discontinue any medication that the client deems to have an allergy towards. Incident Report will be completed promptly and DDAP notified via portal or fax. Nurse Manager will also ensure that order checks are done within 24 hours of verbal or written order and signed off on to ensure there are no medications orders in error. Quality and Risk manager will monitor incident report books on a monthly basis for the next 90 days and then quarterly after. This was completed by May 6 2022
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of fourteen client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of three applicable records reviewed.
Client #12 was admitted on August 18, 2021 and was administratively discharged on October 5, 2021. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor provided training on the involuntary discharge procedure and supporting documentation.
Clinical Supervisor will ensure a client who is involuntarily discharged, will be notified in writing including the reason for termination. Clinical Supervisor will review all involuntary discharges to make sure the correct procedure is followed as well as the documentation showing client was notified in writing of the discharge including the reasons for discharge. Continued monitoring of Involuntary discharges will also be reviewed in the monthly chart audits the Clinical Supervisor completes. This was completed by May 6 2022
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of fourteen client records, the facility failed to document that the client was given the opportunity to request reconsideration of a decision terminating treatment in one of three applicable records reviewed.
Client #12 was admitted on August 18, 2021 and was administratively discharged on October 5, 2021. There was no documentation in the record that the client was given the opportunity to request reconsideration of the decision terminating treatment.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor provided training on the involuntary discharge procedure and supporting documentation. Clinical Supervisor will ensure a client who is involuntarily discharged shows documentation the client was notified in writing including the reason for termination, and given the opportunity to request reconsideration of a decision to terminate. Clinical Supervisor will review all involuntary discharges to make sure the correct procedure is followed as well as the documentation showing the client was informed how to request reconsideration. Involuntary discharges will also be reviewed in the monthly chart audits the Clinical Supervisor completes. This was completed May 6 2022. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client records and unusual incident reports provided by the facility, the facility failed to ensure that events at the facility requiring the presence of police, fire, or ambulance personnel were reported to the Department within three business days. EMT personnel were onsite on February 15, 2022, however, the incident was not reported to the Department until February 24, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Quality and Risk Manager provided re training on the procedure of completing unusual incidents timely.
Nurse manager will ensure a written unusual incident report is filled with the department within 3 business days following an unusual incident involving requiring the presence of police, fire or ambulance personnel. Quality and Risk Manager will review incidents on a monthly basis for compliance. This was completed by May 1 2022.
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709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of seven client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project including a discharge summary in one of one applicable record reviewed.
Client #4 was admitted on February 14, 2022 and discharged on February 22, 2022. The client record did not contain a discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client records will include a discharge summary within 7 days from date of discharge. Clinical supervisor re educated clinicians on the regulations around discharge documentation.
Clinical Supervisor will ensure discharge summaries are being documented and placed in the closed charts in accordance with regulation. Chart #4 has been corrected with the discharge summary placed within the closed chart. Clinical Supervisor will continue to monitor for discharge summaries while completing their monthly chart audits as well as during supervisions. Completed May 1 2022.
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709.64(e) LICENSURE Follow-up policy
709.64. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of client records, the facility failed to follow their written client follow-up policy, to include following up with clients who discharged without being referred to additional services in one of one applicable record reviewed.
Client #4 was admitted on February 14, 2022 and discharged on February 22, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Campus Director reviewed and retrained on the follow up procedure in All Staff Meeting. The facility will follow their written client follow-up policy, and include following up with clients who discharged without being referred to additional services. A follow up was completed on Client #4. Clinical Supervisor will check the follow up binder weekly to ensure follow up calls are being placed on all clients. Completed by May 1 2022 |
715.23(e) LICENSURE Patient records
(e) Patient file records, information and documentation shall be legible, accurate, complete, written in English and maintained on standardized forms or electronically.
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Observations
Based on a review of three patient records, two records contained documentation by the Medical Director that was illegible.
Patient #6 was admitted on January 13, 2022 and was discharged on January 18, 2022. The documentation for present opiate use dated January 13, 2022 was not legible. The date and time the physician reviewed the urine drug screen collected on January 13, 2022 was not legible. The date on the physician approval for activity form was not legible. The date the physician authenticated the physician order for opioid withdrawal protocol was not legible.
Patient #7 was admitted on September 25, 2021 and was discharged on September 30, 2021. The record contained a verbal order on September 25, 2021, the date it was authenticated was not legible.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nurse manager will monitor written documentation from doctor and bring it to director if writing is not legible. Program Director has notified physician of findings. Nurse manager will continue to monitor through monthly chart audits and make director and physician aware if their needs to be corrections made so that the writing of the physician is legible. This will continue to be monitored in monthly chart audits as well. This was completed by May 6 2022. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of seven client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 30 days in one of three applicable records reviewed.
Client #12 was admitted on August 18, 2021 and was discharged on October 5, 2021. The individual treatment and rehabilitation plan was completed on August 26, 2021 and the treatment plan update was due to be completed by September 26, 2021, however, there was no treatment plan update completed prior to the client ' s discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will audit charts monthly to ensure treatment plans are reviewed at least every 30 days. Clinical supervisor will review and educate on regulations around treatment plans in the next Clinical meeting. Clinical Supervisor will continue to monitor and review findings in supervisions to clinical staff. Will be completed by May 20 2022. |
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 a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in four of seven records reviewed.
Client #8 was admitted on September 1, 2021 and was discharged on September 30, 2021. The treatment plan completed on September 8, 2021, indicated that the client was to receive one dual group per week; however, the record contained no documentation of dual groups prior to the client ' s discharge.
Client #10 was admitted on January 18, 2022 and was active at the time of the inspection. The treatment plan completed on January 19, 2022, indicated that the client was to receive one dual group per week; however, the record contained no documentation of dual groups prior to the client ' s discharge. Additionally, the treatment plan on January 19, 2022 indicated the frequency of individual treatment sessions to be weekly, and there was no change to the type and frequency of counseling noted on treatment plan updates. However, the client had not received an individual session since February 12, 2022.
Client #12 was admitted on August 18, 2021 and was discharged on October 5, 2021. The treatment plan completed on August 6, 2021 indicated the frequency of individual treatment sessions to be weekly; however, the client had not received an individual session since September 14, 2021.
Client #14 was admitted on April 7, 2022 and was active at the time of the inspection. The treatment plan completed on April 15, 2021, indicated that the client was to receive one dual group per week; however, the record contained no documentation of dual groups prior to the client ' s discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will provide education to all clinical staff around documentation of the dual group notes and ensuring the services provided follow along with the individuals treatment plan. Clinical Supervisor will audit charts monthly to ensure counselors are completing dual groups/notes to coincide with the dual treatment plans as well as individual sessions are documented and filed. Clinical supervisor will continue to monitor and address any findings in supervisions from chart audits. This was completed by May 1 2022. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of six applicable client records, the facility failed to ensure the record of services provided had supporting progress notes to determine those services were provided as documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor went over record of service documentation and corresponding documentation at the weekly Clinical Meeting. Clinical Supervisor will ensure the record of services has supporting progress notes to determine those services documented in the record of service were provided as documented. For the next 90 days clinical supervisor will review documentation from psycho educational lectures are being placed in the charts as documented on the record of service. Clinical supervisor will continue to monitor the notes that match the record of service are being placed in the charts while completing the monthly chart audits. This was completed by May 6 2022.
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709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
Based on a review of three out of three applicable records, the facility failed to follow their written client follow-up policy, to include following up with clients who discharged without being referred to additional services.
Client #8 was admitted on September 1, 2021 and discharged on September 30, 2021.
Client #11 was admitted on September 30, 2021 and discharged on October 6, 2021.
Client #12 was admitted on August 18, 2021 and discharged on October 5, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Campus Director reviewed and retrained on the follow up procedure in All Staff Meeting. The facility will follow their written client follow-up policy, and include following up with clients who discharged without being referred to additional services. A follow up was completed on Client #8,Client #11 and Client #12. Clinical Supervisor will check the follow up binder weekly to ensure follow up calls are being placed on all clients. Completed by May 6 2022 |