INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 14, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, 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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709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of patient records and the Ordering, Transcribing, Obtaining and Reconciling Medications policy, the facility failed to implement its written policy and procedures regarding all medications used by clients in two of seven records reviewed.
The Ordering, Transcribing, Obtaining and Reconciling Medications policy states if a medication is not available, the physician will be informed in order to obtain an order for an alternative therapy. In all instances where a medication is ordered, but is unable to be administered, an incident report is to be completed if the physician does not order a substitute medication.
Client # 6 was admitted on November 5, 2023, and discharged on December 5, 2023. Per documentation reported in the medical record, a medication was unavailable to administer due to the facility waiting on delivery November 17, 20 and 21, 2023. Another medication was documented as not being administered between November 17-20, 2023, also waiting on delivery. There was no documentation of on incident report being written or a substitute medication being ordered.
Client # 7 was admitted on November 12, 2023, and discharged on December 8, 2023. Per documentation reported in the medical record, a medication was unavailable to administer due to the facility waiting on delivery November 18-19, 2023. There was no documentation of on incident report being written or a substitute medication being ordered.
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Plan of Correction
Facility will implement its written policy and procedure regarding medication use by clients.
Over the next 60 days the Nurse Manager will review all client medications on a weekly basis to ensure clients have access to all written orders regardless of insurance.
Ongoing, the Nurse Manager will continue to monitor medication orders and immediately notify the Medical Director. Arrangements will be made to obtain the pharmaceutical. |
709.34 (c) (5) 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:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
Based on a review of patient records, the facility failed to inform the Department of an unusual incident involving an outbreak of a contagious disease within the required three days. A client tested positive for COVID-19 and was quarantined on November 14, 2023. An unusual incident report was not submitted to DDAP.
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Plan of Correction
Facility will inform the Department of any unusual incidents involving the outbreak of a contagious disease.
The Campus Director and Risk Manager together will review all unusual incident reports over the next 90 days to ensure notificatino is made to the department. Training will be conducted with all staff within the next 30 days to ensure that they are aware of the policies and procedures to be followed.
Ongoing, the Campus Director and Risk Manager together will review all unusual incident reports to ensure necessary incidents are being reported to the department. |
709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
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Observations
Based on a review of patient records, the facility failed to provide information relative to the patient's involvement in the project, which is to include a complete Medication Record, in two of seven patient records reviewed.
Client # 4 was admitted on November 4, 2023, and discharge on November 28, 2023. The Medication Record was missing information involving the administration of medication on November 13, 24, and 27, 2023.
Client # 6 was admitted on November 5, 2023, and discharged on December 5, 2023. The Medication Record was missing information involving the administration of medication on November 16, 19, and 22, 2023.
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Plan of Correction
Facility will provide information relative to patient involvement in the project including a complete Medical Record.
The Nurse Manager will retrain the nursing staff at the next Nursing Department meeting which will occur within 30 days to ensure there are no blanks left in any Medical Record.
Ongoing, the Nurse Manager will conduct weekly audits for the next 60 days and thereafter on a monthly basis to ensure that a complete Medical Record will be in place for each patient who is involved in the project. |