INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 11 through 12, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run Of Lancaster 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 and a plan of correction is due on April 5, 2009.
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Plan of Correction
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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 the review of client records, the facility failed to document consents to release information in one of five client records reviewed.
The findings include:
Ten client records were reviewed on March 11 through 12, 2009. Consents to release information were required in five of five client records. The facility did not document a consent to release information before a release was made to a government agency in client record # 2.
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Plan of Correction
The facility will ensure that appropriate Consents to Release are completed for all clients. Re-fresher training will be provided to all staff having responsibility for completion of the Consent forms by the Facility Clinical Supervisor. Re-fresher training will be developed by 5/1/2009 and implemented prior to 5/15/2009. The Clinical Supervisor and Nurse Coordinator will also conduct on-going file audits to inspect client files for compliance with the regulation. A staff meeting will also be scheduled to review the confidentiality policy with all facility staff to include the requirement that staff inspect the client file prior to making a contact and ensuring that a Consent to Release is completed before any information is shared. A staff meeting will be held prior to 5/1/2009. |
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 the review of client records, the facility failed to document complete psychosocial evaluations in two of two client records.
The findings include:
Four client records were reviewed on March 11 through 12, 2009. Psychosocial evaluations were required in two client records from the detoxification only level of treatment. The facility did not document complete psychosocial evaluations in client records # 1 and 2. Client record # 1 was missing the composite picture, assets/strengths, support systems, coping mechanisms, negative factors, and counselor conclusions/impressions. Client record # 2 was missing composite picture, client problems/needs, assets/strengths, support systems, coping mechanisms and the client's attitude towards treatment.
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Plan of Correction
While the Psychosocial Evaluation was completed on all clients, there is a concern that the information contained in the Evaluation does not contain sufficient detail. The facility Administrator, Clinical Supervisor, and Nurse Manger, will develop and conduct a training and an on-going review process for the Clinical and Nursing staff to ensure the level of quality and content of the client file meets regulatory requirements. A refresher training program will be developed by 5/1/2009 and conducted prior to 5/15/2009. Re-training will consist of how to properly and completely document: composite picture of the client; assets and strengths; support systems; coping mechanisms; negative factors; client attitude toward treatment; and counselor conclusions/impressions. The Nursing Coordinator and Clinical Supervisor will also conduct on-going reviews of client clinical files and address any quality concerns through the clinical supervision process. |
709.51(a)(1) LICENSURE Criteria for Admission
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
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Observations
Based on the review of client records and facility staff verbal confirmation, the facility failed to ensure that clients met the criteria for admission for the inpatient non-hospital - residential treatment and rehabilitation in two of two client records reviewed.
The findings include:
Nine client records were reviewed on March 11 through 12, 2009. Partial hospitalization clients attended inpatient therapeutic groups in two of two client records reviewed, # 5 and 6.
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Plan of Correction
White Deer Run of Lancaster has not admitted any clients to the Partial Program since the Licensing inspection. There are currently no clients enrolled in the program and no new clients will be admitted until the POC is accepted by Licensing and a written plan for admission completed and implemented.. The facility will correct the deficiency by developing a written plan that establishes formal criteria for admission and intake. This will include: type of client (e.g., age, sex, physical and/or mental conditions, etc.), level of service need and nature of the D&A problem, and any special limitations (e.g., handicapped, dual diagnosis, psychotic, non-English speaking, etc.). The facility administrator and clinical director will develop the plan and submit to corporate leadership for approval. Upon approval from corporate leadership the clinical staff and administrative intake staff will be trained on the intake/admission protocol and the plan implemented prior to accepting any new clients into the program. A moratorium on admitting any clients into the Partial program will remain in effect until the written plan is completed, approved, and fully implemented. Anticipated date of completion: May 15, 2009
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