INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 15-16, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated 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:
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Plan of Correction
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, it was observed that the facility failed keep the facility in good repair at all time for the safety and well being of residents, employees and visitors as evidence by the following: 1.It was observed that building #1 had a hole in the shower located in room 201, a crack in the shower of room 205 as well as a hole in the wall in room 205. 2.It was observed that building #2 had a hole in the ceiling of Room#2.3.It was observed that building #5 had a client door and wall with a hole in it.4.It was observed that building #17 ' s front room contained a crack in the wall. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Maintenance department will screen, patch and plaster building #1 room 201 (hole in shower) and 205 (crack in shower and hole in wall), building #2 room #2 (hole in ceiling), building #5 (hole in wall), building #17 (crack in wall)
The maintenance department will replace the door in building #5
Leadership rounds will be conducted by management team weekly to monitor the physical plant. Results of the physical plant audit will be sent to maintenance, risk, CEO, COO and QI to monitor corrections are being made.
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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 on a physical plant inspection, it was observed that the facility failed to ensure the safety and well-being of clients, staff, and visitors as evidenced by the following:1.It was observed that the banister/railing at the top of the porch on the back exit of building #1 was loose and not secured to the floorboards and could create a falling hazard to clients, employees or visitors. 2.It was observed that the banister/railing on the porch of building #3 was not secured to the floorboards and could create a hazard to clients, employees or visitors.3.It was observed that the banister/railing on the porch of building #11 and the floorboards were not secure and could create a hazard to clients, employees or visitors. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Maintenance staff secured/tightened the banister/railings on building #1, #3 to the floorboards
Maintenance staff secured the floorboards and the banister/railing of building #11.
Leadership rounds will be conducted by management team weekly to monitor the physical plant. Results of the physical plant audit will be sent to maintenance, risk, CEO, COO and QI to monitor corrections are being made.
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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 on a review of client records and discussion with facility staff, the facility failed to complete and document a psychosocial evaluation for all clients. Client record #9 was admitted on September 15, 2020 and was still active at the time of inspection.Client #10 was admitted on September 11, 2020 and was still active at the time of the inspection.Client #11 was admitted on September 6, 2020 and was still active at the time of the inspection. Client #12 was admitted on August 29, 2020 and was discharged on September 5, 2020. Client #13 was admitted on August 5, 2020 and was discharged on August 10, 2020.Client #14 was admitted on September 9, 2020 and was discharged on September 11, 2020.These findings were discussed with facility staff during the inspection process. This is a repeat citation from the last inspection on May 3, 2019.
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Plan of Correction
Detox counselors will completed the biopsychosocial assessment and diagnostic summary within 72 hours of admission.
Detox supervisor will monitor and track the completion of the biopsychosocial assessments and diagnostic summaries and send out daily reports to clinical supervisor, CEO and COO. Float counselors will be utilized to assist detox and rehab counselors to ensure that biopsychosocial assessments and diagnostic summaries are completed within 72 hours timeframe.
Rehab counselors will complete biopsychosocial assessment and diagnostic summaries within 72 hours of admission to rehab, or will review and update biopsychosocial assessment/diagnostic summary completed during detox program.
Medical records will conduct weekly chart audits to ensure biopsychosocial assessments and diagnostic summaries are completed within regulatory standards. Audit findings will be provided to clinical supervisors to address findings and compliance standards during supervisions and may lead to disciplinary action.
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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 plan in client records #1, #2 and #3. Client record # 1 was admitted on August 26th, 2020 and was still active at the time of inspection. The comprehensive treatment plan, dated September 3, 2020, indicated five group sessions per week. The chart's record of service and progress notes indicated that the client only received three group session ' s the week of August 31st, 2020 and four group sessions the week of September 6, 2020.Client record # 2 was admitted on August 15th, 2020 and was still active at the time of inspection. The comprehensive treatment plan, dated August 20, 2020, indicated five group sessions per week. The chart's record of service and progress notes indicated that the client only received four group session ' s the week of August 31st, 2020 and three group sessions the week of September 6, 2020.Client record # 3 was admitted on August 11th, 2020 and was still active at the time of inspection. The comprehensive treatment plan, dated August 13th, 2020, indicated five group sessions per week. The chart's record of service and progress notes indicated that the client only received one group session ' s the week of August 23rd, 2020 and four group sessions the week of August 31st, 2020.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Staff Members responsible for charts #1, 2, 3 were met with to review regulatory standards around treatment plan matching services received. These counselors have been put on a daily auditing flow sheet to ensure they are getting their daily documentation completed. The audit sheet is completed by the staff daily and reviewed with their supervisor.
Clinical supervisors will monitor and track clinical services to ensure that treatment plans match services offered and that documentation is completed within 48hrs of receiving the service.
Supervisors received supervision reviewing the regulatory standard 709.52 treatment and rehabilitation services (c ) counseling services are provided according to the individual treatment and rehabilitation plan.
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