INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 17 & 18, 2008 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 May 15, 2008.
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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 upon a review of personal records on April 8 - 11, 2008 and April 18, 2008, the facility failed to ensure that staff persons and volunteers received 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 within the required time frames. One of nine client records reviewed, #7, lacked documentation to verify that the employee had completed their TB/STD training within two years of their hire date.
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Plan of Correction
General Training Requirements will be reviewed with all managers during May Management meeting. Trainings for TB/STD/HIV will be scheduled within 8 weeks to ensure that all support staff meet compliance. This will be addressed by QI and Regional Administrator. |
709.81(b)(5) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based upon a review of client records on April 17-18, 2008, the facility failed to document the clients' temperatures and/or respirations on physical examination documents in two of two client records reviewed. Client record #1 lacked the client's temperature and client record #7 lacked the client's temperature and respiration.
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Plan of Correction
Vital signs will be included in the History and Physical for all patient evaluations effective 5/1/08. Compliance will be monitored through random chart audits conducted by the nursing department for 30 days with audit findings documented on the facility chart audit form. The threshold will be set at 100% compliance reviewing 100% of open charts. If after 30 days there is not 100% compliance, the audit will continue weekly for an additional 30 days until there is 100% compliance in this area. All medical staff will be re-trained on documenting vital signs on the history and physical by the Senior/Lead Nurse beginning 5/1/08. The reviews will be conducted by the RN or LPN. |
709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
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Observations
Based upon a review of client records on April 17-18, 2008, the facility failed to document the clients' temperatures and/or respirations on physical examination documents in four of seven client records reviewed. Client records #1 and 2 lacked the clients' temperature and client records #6 & 7 lacked the clients' temperature and respiration.
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Plan of Correction
Vital signs will be included in the History and Physical for all patient evaluations effective 5/1/08. Compliance will be monitored through random chart audits conducted by the nursing department for 30 days with audit findings documented on the facility chart audit form. The threshold will be set at 100% compliance reviewing 100% of open charts. If after 30 days there is not 100% compliance, the audit will continue weekly for an additional 30 days until there is 100% compliance in this area. All medical staff will be re-trained on documenting vital signs on the history and physical by the Senior/Lead Nurse beginning 5/1/08. The reviews will be conducted by the RN or LPN. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based upon a review of client records on April 17-18, 2008, the facility failed to document the clients' temperatures and/or respirations on physical examination documents in four of seven client records reviewed. Client records #1 & 2 lacked the clients' temperature and records #6 & 7 lacked the clients' temperature and respiration.
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Plan of Correction
Vital signs will be included in the History and Physical for all patient evaluations effective 5/1/08. Compliance will be monitored through random chart audits conducted by the nursing department for 30 days with audit findings documented on the facility chart audit form. The threshold will be set at 100% compliance reviewing 100% of open charts. If after 30 days there is not 100% compliance, the audit will continue weekly for an additional 30 days until there is 100% compliance in this area. All medical staff will be re-trained on documenting vital signs on the history and physical by the Senior/Lead Nurse beginning 5/1/08. The reviews will be conducted by the RN or LPN. |