INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring inspection conducted on March 23-24, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the 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 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on an observation during the physical plant inspection, it was determined that the project failed to maintain all structures on the grounds of the facility so as to be free from any danger to health or safety or in good repair at all times for the safety and well being of residents, employees, and visitors.The findings include:An inspection of the residential portion of the facility was conducted on March 23, 2016 at approximately 10:00 am to 1:00 pm. Building #3, the Annex - There have been multiple incidents of damage to the outdoor siding on all sides of the building. The siding had tears with sharp edges that posed a safety risk to residents, employees, and visitors. Building #1 - In the transportation office on the first floor, there was one electrical outlet without an electrical outlet face plate, posing a safety risk.Building #13 - The building where the laundry is done did not appear to be maintained as evidenced by numerous amount of paint peeling off of the structure. Additionally, upon entering the building, there was water all over the walk area of the floor that could not be explained. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance department will purchase new siding and repair damaged areas.
Maintenance staff replaced the electrical outlet cover on 3/23/16.
Maintenance staff removed washing machine that was leaking and replaced it with new washing machine on 3/23/16.
Building #13 interior is scheduled to be repainted by maintenance staff
Physical plant will be monitored through leadership rounds conducted weekly by management team and monthly walk through conducted by the maintenance department staff. Facility Director will assure compliance.
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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 an observation during the physical plant inspection, it was determined that the project failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The findings include:An inspection of the residential portion of the facility was conducted on March 23, 2016 at approximately 10:00 am to 1:00 pm. Building # 1 - 2nd floor Bathrooms in room 208 and 206 had molding and caulking that was peeling away from the showers. Bathroom in room 202 had a sink that was coming away from the wall. Bathroom in room 201 had a vent located on the ceiling that had a working light but the vent was missing the cover to the light.Room 209 had a broken light fixture above a bed. The shade of the florescent light was cracked and hanging off the fixture.Building #11First stall door on the left, located in the bathroom next to room 3, was hanging by the hinge with drywall breaking away from the wall. Building #24Bathrooms in room 1 and 2 had broken tile with pieces missing in their bathrooms. Bathroom in room 6 had a radiator in the bathroom that was covered in rust. Building #25 Bathroom in room 25-4, had black mold in the cracks of the shower. Bathroom in room 25-6, there was missing trim molding outside of the shower. Bathroom in room 25-9, bathroom had tile coming up off the floor under the sink. Bathroom in room 25-10, had a small hole to the lower right of the shower in the wood work with black mold. Bathroom in room 25-11, had a big hole in the wall exposing wood behind it above the bed of a resident. In the bathroom, trim molding was pulled away from the wall.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Building #1 upstairs, all shower areas will be re-caulked, repaired, replaced and remodeled as needed by maintenance staff.
Maintenance staff repaired the wall and fixed the hinges on the stall in building #11 on 3/23/16.
Maintenance staff replaced the broke tile in Building #24 bathrooms as well as the rusted floor vent on 3/29/16.
Building #25, all shower areas will be re-caulked, repaired, replaced and remodeled as needed by maintenance staff. Additionally, any holes in walls will be patched and painted by maintenance staff.
Physical plant will be monitored through leadership rounds conducted weekly by management team and monthly walk through conducted by the maintenance department staff. Facility Director will assure compliance.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of the project's consent to release, the facility failed to inform clients of their right to verbally revoke a consent to release of information in six of fourteen client records.The findings include:Fourteen client records were reviewed on March 23-24, 2016. The "Authorization for Release of Information" form did not contain documentation of the client's right to verbally revoke a signed consent for the release of information. The facility's "Authorization for Release of Information" form documented, "I may revoke this authorization at any time. Revocations to this authorization must be presented in writing."Client #5 was admitted on March 5, 2016 and was still an active client at the time of inspection. The facility failed to comply with 42 CFR as the consent required the client to revoke the consent form in writing.Client #6 was admitted on March 2, 2016 and was still an active client at the time of inspection. The facility failed to comply with 42 CFR as the consent required the client to revoke the consent form in writing.Client #7 was admitted on February 25, 2016 and was still an active client at the time of inspection. The facility failed to comply with 42 CFR as the consent required the client to revoke the consent form in writing.Client #8 was admitted on March 15, 2016 and was still an active client at the time of inspection. The facility failed to comply with 42 CFR as the consent required the client to revoke the consent form in writing.Client #12 was admitted on February 23, 2016 and discharged on March 9, 2016. The facility failed to comply with 42 CFR as the consent required the client to revoke the consent form in writing.Client #13 was admitted on March 11, 2016 and discharged on March 21, 2016. The facility failed to comply with 42 CFR as the consent required the client to revoke the consent form in writing.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
QI Coordinator facilitated a training directing staff to write "may verbally revoke" on each patients consent
All patient records to date have the correction made to them.
Medical Records will randomly check 5 charts per week for the next 8 weeks to ensure consents are correct.
IT department will correct the EMR consents by adding the "verbal revocation" to the consent, removing the HIV related information and removing the section identifying whether D&A, MH, HIV records may be released.
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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 client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of two client records.The findings include:Two client records requiring written notification to the client of facility's decision to involuntarily terminate the client's treatment were reviewed on March 23, 2016 and March 24, 2016. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the facility in client record #11.Client # 11 was admitted into treatment on September 23, 2015 and was involuntarily terminated from the facility on October 13, 2015. There was no documentation of written notification of the facility's decision to involuntarily terminate the client's treatment as of the date of the on-site inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
QI will send termination of treatment form and appeal form to all staff.
Clinical director will train clinical staff on the documentation and use of termination of treatment form.
Clinical supervisor will audit AD charts to ensure compliance of termination of treatment form.
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