INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and an on-site inspection conducted for the approval to use a narcotic agent, specifically buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on March 9, 2016 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.
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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 on a review of personnel and training records, the facility failed to provide documentation of HIV/AIDS and TB/STD training in one of seven applicable records reviewed.
The findings include:
Seven personnel records which required documentation of mandatory communicable disease training were reviewed on March 9, 2016. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee #5.
Employee #5 was hired 3/3/2014 as a driver. This employee was required to obtain six hours of HIV/AIDS and 4 hours of TB/STD training by 3/3/2016. Employee #5 failed to obtain the training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on an observation during the physical plant inspection, the facility failed to keep frozen food at or below 0 degrees fahrenheit in one of two freezers.
The findings include:
A physical plant inspection was conducted on March 9, 2016 at approximately 10:30 am.
A freezer holding food that is located in the laundry room of Kitchen Hall, had a thermometer that read 2 degrees fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of the fire extinguisher upon employment, in two of seven personnel records.
The findings include:
Seven personnel records were reviewed on March 9, 2016. The facility failed to document the completion of fire extinguisher training upon employment, in personnel records #4 and #7.
Employee # 4 was hired on May 18, 2015. There was no record that this training was complete by the date of the inspection.
Employee # 7 was hired on November 10, 2015. There was no record that this training was complete by the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff to perform assigned tasks during emergencies in two of seven personnel records.
The findings include:
Seven personnel records were reviewed on March 9, 2016. The facility failed to document the completion of emergency training in personnel records, #4 and 7.
Employee # 4 was hired on May 18, 2015. There was no record that this training was complete by the date of the inspection.
Employee # 7 was hired on November 10, 2015. There was no record that this training was complete by the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 the review of the fire drill record, the facility failed to ensure that fire drills were accurately documented on the fire drill reports.
The findings include:
The fire drill record was reviewed on March 9, 2016. Twelve months of fire drills were reviewed. The facility's hours of operation are from 24 hours a day, seven days a week.
Fire drills for 10/11/15, 9/30/15 and 8/3/2015 all state "Time of Activated Alarm" was 2:45 pm. Fire drills for 3/31/2015 and 4/29/15 do not state if the time was a.m. or p.m.
In addition, the fire drill for 11/10/15 did not indicate if this was an actual fire, a false alarm, or a fire drill; and the fire drill for 1/29/2016 did not indicate the exit route used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in eight of eight client records.
The findings include:
Eight client records were reviewed on March 9, 2016 for informed and voluntary consent to release client information forms. The facility failed to obtain an informed and voluntary consent to release information from the client in client records #1 through #8.
The facility's consent to release client information form is a standardized form. The consent form included the following statement: "I may revoke this authorization at any time. Revocations to this authorization must be presented in writing. Revocation will not apply to information disclosed prior to receiving a written revocation."
42 CFR Part 2, Subpart C, subsection 2.31 (a) Required elements, specifies that the following information must be included on the written consent: "(8) A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it." Therefore, as per 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) the consent to release client information form can be revoked by the client at any time and there is no restriction on the manner in which they may revoke it.
The facility failed to adhere to the requirements outlined in the federal confidentiality regulations by requiring the clients to revoke consent forms in writing.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 patient records, the facility failed to document a psychosocial evaluation in two of four detox patient records.
The findings include:
Four client records were reviewed on March 9, 2016. Four patient records required the documentation of a psychosocial evaluation. The facility failed to provide documentation of a psychosocial evaluation in patient records, # 1 and 3.
Client # 1 was admitted to the inpatient detox activity on March 4, 2016 and transferred to the inpatient rehabilitation activity on March 9, 2016. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.
Client # 3 was admitted to the detox activity on December 4, 2015 and transferred to the inpatient rehabilitation activity on December 10, 2015. As of the date of patient #3's transfer, there was no documentation of a psychosocial evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.63(a)(2) LICENSURE D & A support 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:
(2) Drug and alcohol support plan.
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Observations
Based on a review of four patient records, the facility failed to have a complete record in four of four inpatient nonhospital activities, short term detoxification records reviewed.
The findings include:
Four inpatient nonhospital activities, short term detoxification patient records were reviewed on March 9, 2016. The facility failed to document a complete drug and alcohol support plan that reflected the project's efforts to support and motivate the client to seek formal treatment after the detoxification process in patient records, #1, 2, 3, and 4.
Client # 1 was admitted to the inpatient detox activity on March 4, 2016 and transferred to the inpatient rehabilitation activity on March 9, 2016. As of the date of the licensing inspection there was no documentation of a drug and alcohol support plan.
Client # 2 was admitted to the inpatient detox activity on March 7, 2016 and there was no documentation of a drug and alcohol support plan as of the date of the licensing inspection.
Client # 3 was admitted to the inpatient detox activity on December 4, 2015 and transferred to the inpatient rehabilitation activity on December 10, 2015. As of the date of patient #3's transfer, there was no documentation of a drug and alcohol support plan.
Client # 4 was admitted to the inpatient detox activity on October 18, 2015 and transferred to the inpatient rehabilitation activity on October 23, 2015. As of the date of patient # 4's transfer, there was no documentation of a drug and alcohol support plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |