INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on February 10, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on a review of five of the seven personnel records and discussion with facility staff, the facility failed to ensure that at least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff as all trainings were provided by health stream.
These findings were discussed with facility staff during the inspection process.
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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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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 (SRFSR) and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for facility directors in employee #2's employee record.
Employee #2 was hired as the facility director on October 3, 2021 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 2022 through December 2022. Employee #2's employee record only documented 6.54 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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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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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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #3 and #5's employee record.
Employee #3 was hired as a counselor on February 1, 2021 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 2022 through December 2022. Employee #3's employee record only documented 22.30 hours of annual training for the training year reviewed.
Employee #5 was promoted to counselor on January 24, 2021 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 2022 through December 2022. Employee #5's employee record only documented 10.49 hours of annual training for the training year reviewed
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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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704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 40 clock hours of annual training required for counselor assistants in the first year of employment in employee #7's employee record.
Employee #7 was hired as a counselor assistant on December 30, 2021 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 2022 through December 2022. Employee #7's employee record only documented 10.21 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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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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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 two of fourteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure
Client # 3 was admitted on February 8, 2023 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated February 8, 2023 to an emergency contact did not include the purpose of the disclosure.
Client # 4 was admitted on November 3, 2022 and was discharged on November 8, 2022. An informed and voluntary consent from the client for the disclosure of information dated November 3, 2022 to an outside agency did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Upon hire, staff responsible for completing consents will receive one on one training with their supervisor on how to properly complete a consent. Competency assessment will be completed after the training.
All staff responsible for completing consents will be required to take DDAP Confidentiality training on PA Train within the first 90 days of hire. Training certificates will be maintained in employee training files.
Quality Director will conduct confidentiality training during all new employee orientation trainings, which will include training on how to complete a consent. New employee orientation will occur on a monthly basis, as needed.
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.
Client #3 has been discharged from the facility and a valid consent is unable to be obtained.
Client #4 has been discharged from the facility and a valid consent is unable to be obtained.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on one of fourteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include if the client was offered a copy of the consent.
Client # 8 was admitted on December 21, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated February 6, 2023 to an outside agency did not include if the client was offered a copy of the consent.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Within 30 days of hire, staff responsible for completing consents will receive one on one training with their supervisor on how to properly complete a consent. Competency assessment will be completed after the training.
All staff responsible for completing consents will be required to take DDAP Confidentiality training on PA Train within the first 180 days of hire. Training certificates will be maintained in employee training files.
Quality Director will conduct confidentiality training during all new employee orientation trainings, which will include training on how to complete a consent. New employee orientation will occur on a monthly basis, as needed.
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.
Client #8 is still present at the facility and a valid consent will be obtained to correct the deficiency.
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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 that facility's unusual incident records, the facility failed to report the Department within 3 business days an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
There was documentation of events for the following dates that required the presence of police, fire or ambulance personnel that were never reported to the department:
2/24/2022, 3/3/2022, 4/6/2022, 5/28/2022, 6/3/2022, 6/13/2022, 6/22/2022, 6/26/2022, 7/18/2022, 7/26/2022, 8/10/2022, 8/14/2022, 8/17/2022, 8/22/2022, 8/25/2022, 8/31/2022, 9/1/2022, 9/8/2022, 9/13/2022,9/19/2022, 9/26/2022, 9/27/2022, 10/18/2022, 10/20/2022, 10/21/2022, 10/26/2022, 10/27/2022, 10/28/2022, 11/1/2022, 11/6/2022, 11/7/2022, 12/8/2022, 12/18/2022, 1/15/2023, 1/9/2023, 1/12/2023, 1/17/2023, 1/19/2023, 1/20/2023
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Unusual Incident reporting will be completed by the nurse manager or clinical supervisor per 709.34 (c)(4) regulation. Regional Nurse Manager and Quality Director will monitor reporting vs. the facility incident reports on a monthly basis for compliance.
The unusual incidents that were not entered, resulting in a citation, will be entered within the next 30 days. The dates of the incidents are as follows:
2/24/2022, 3/3/2022, 4/6/2022, 5/28/2022, 6/3/2022, 6/13/2022, 6/22/2022, 6/26/2022, 7/18/2022, 7/26/2022, 8/10/2022, 8/14/2022, 8/17/2022, 8/22/2022, 8/25/2022, 8/31/2022, 9/1/2022, 9/8/2022, 9/13/2022,9/19/2022, 9/26/2022, 9/27/2022, 10/18/2022, 10/20/2022, 10/21/2022, 10/26/2022, 10/27/2022, 10/28/2022, 11/1/2022, 11/6/2022, 11/7/2022, 12/8/2022, 12/18/2022, 1/15/2023, 1/9/2023, 1/12/2023, 1/17/2023, 1/19/2023, 1/20/2023
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709.63(a)(6) LICENSURE Aftercare plan
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:
(6) Aftercare plans, if applicable.
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Observations
Based on one of four applicable client records reviewed, the facility failed to provide an aftercare plan upon successful discharge of client # 6.
Client # 6 was admitted on December 30, 2022 and was discharged on January 4, 2023.There was no aftercare plan available in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Counselor Assistant will complete the aftercare (continuing care) plan with each detox client.
The discharging nurse will complete the discharge checklist with each discharging client. The discharge checklist lists the aftercare (continuing care) plan. Both the discharging nurse and the discharging client will sign off on the discharge checklist ensure all required discharge paperwork is completed.
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.
The aftercare plan for client #6 is unable to be completed because the client has already discharged.
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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 one of four applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual. The policy and procedure manual indicates a discharge summary be completed within 7 days of discharge.
Client # 7 was admitted on October 24, 2022 and was discharged on October 29, 2022. The discharge summary was due to be completed no later than November 5, 2022; however, the discharge summary was not completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The discharging nurse will complete the discharge summary for each client who discharges from detox.
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.
The Discharge Summary for Client #7 will be completed and placed in the medical record.
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709.63(a)(8) LICENSURE Follow-up Information
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:
(8) Follow-up information.
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Observations
Based on one of four applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur 30 days after discharge.
Client # 7 was admitted on October 24, 2022 and was discharged on October 29, 2022. There was no follow-up information available in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Counselor Assistant will complete a follow up on all clients discharged from the facility. The follow up will be completed no later than 30 days after discharge.
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.
Client #7 record has been corrected to reflect a completed follow up.
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