INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on March 20, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of 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. The following deficiencies were identified during this inspection:
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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 records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #7 was hired as a Behavioral Health Tech Supervisor on March 5, 2014, and was due to have the communicable disease trainings no later than March 5, 2016. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #8 was hired as a Behavioral Health Tech on January 12, 2022, and was due to have the communicable disease trainings no later than January 12, 2024. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #9 was hired as a Behavioral Health Tech on August 12, 2022, and was due to have the communicable disease trainings no later than August 12, 2024. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #10 was hired as a Behavioral Health Tech on March 21, 2022, and was due to have the communicable disease trainings no later than March 21, 2024. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #11 was hired as a Behavioral Health Tech on December 26, 2021, and was due to have the communicable disease trainings no later than December 26, 2023. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #12 was hired as a Cook on March 24, 2022, and was due to have the communicable disease trainings no later than March 24, 2024. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #13 was hired as an Admission Coordinator on March 9, 2020, and was due to have the communicable disease trainings no later than March 9, 2022. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility will follow the Mandatory Communicable Disease Training requirements from DDAP for all employees.
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.
Ongoing: HR and the Campus Director will ensure that all current staff receive the required trainings and that all newly hired staff will receive the the required trainings in the prescribed time frames. |
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 a physical plant inspection, the facility failed to maintain freezer temperatures according to the regulation. The facility's dining room freezer temperature was measured at 29 at the time of the inspection.
This finding was reviewed with the facility during the licensing process.
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Plan of Correction
The facility will ensure that freezer temperatures are maintained at or below 0 degrees Fahrenheit as required.
A new thermometer will be placed in the all freezer units confirming that frozen food is maintained at or below 0 degrees Fahrenheit.
Ongoing: Dietary staff will review and record temperature in all freezer units on a daily basis. For the next 90 days, the BHA Supervisor and Campus Director will review the temperature logs on a weekly basis to ensure that the freezers are maintaining frozen food at the appropriate temperature. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of residential client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in three of three applicable client records reviewed.
Per the requirement in the DDAP Licensing Alert 02-21 the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice
Client #8 was admitted on June 21, 2024, and was discharged against medical advice on July 10, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client #9 was admitted on October 24, 2024, and was discharged against medical advice on October 28, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client #10 was admitted on August 2, 2024, and was discharged against medical advice on August 5, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice 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
The facility will maintain a complete client record for each client which shall include notification of emergency contacts within 12 hours of discharge for all clients leaving treatment Against Medical Advice.
For the next 60 days, the Nurse Manager will audit all charts of clients who discharge against medical advice on a weekly basis to ensure that the clients emergency contacts were notified within 12 hours of discharge.
Ongoing: The Nurse Manager will conduct quarterly chart audits for all clients who discharged against medical advice to ensure that the clients emergency contacts were notified within 12 hours of discharge.
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709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of fire drill and emergency logs, the facility failed to file a written unusual incident report with the Department within three business days following an unusual incident involving: event at the facility requiring the presence of police, fire or ambulance personnel.
During the renewal inspection, DDAP staff observed multiple " Emergency Event/Drill Reports " completed by the facility dated March 26, 2024, August 14, 2024, and September 30, 2024. These reports stated that the fire department came to the facility to respond to a fire alarm. The facility was unable to provide documentation that these incidents were reported to DDAP.
Additionally, DDAP staff observed an " Emergency Event/Drill Report " completed by the facility dated May 19, 2024. This report stated that an ambulance came to the facility to respond to a client medical incident. The facility was unable to provide documentation that this incident was reported to DDAP.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The facility will ensure that a written unusual incident report will be filed with the Department within 3 days following an unusual incident.
The Nurse Manager will review the fire drill and emergency logs on a daily basis to ensure that unusual incident reports are filed with the Department within 3 days of the occurrence of an unusual incident.
Ongoing: The Nurse Manager will conduct quarterly audits of the fire drill and emergency logs to ensure that unusual incident reports were filed with the Department within 3 days of any unusuall incident. |
709.63(a)(8) LICENSURE Follow-up Information
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:
(8) Follow-up information.
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Observations
Based on a review of detox client records, the facility failed to provide a complete client record, which is to include follow-up information in three out of four applicable client records reviewed.
The facility's policy is to follow-up on all clients within thirty-days of discharge regardless of their discharge status.
Client #3 was admitted on November 27, 2024, and was discharged on December 2, 2024. The client record did not contain documentation of a follow-up contact.
Client #4 was admitted on December 5, 2024, and was discharged on December 10, 2024. The client record did not contain documentation of a follow-up contact.
Client #5 was admitted on December 16, 2024, and was discharged on December 21, 2024. The client record did not contain documentation of a follow-up contact.
This is a repeat citation from the February 5, 2024, and February 10, 2023 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility shall maintain a complete client record which includes follow-up contact within 30 days of discharge from detox, no matter the clients discharge status.
For the next 60 days the Clinical Director will audit five charts per week to ensure they include documentation of a follow-up contact within 30 days of a clients discharge from detox no matter the status of the discharge.
Ongoing: The Clinical Director will conduct quarterly chart audits to ensure follow-up contacts were made within 30 days of discharge from detox no matter the status of the discharge. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of residential client records, the facility failed to provide a complete client record, which is to include follow-up information in two out of four applicable client records reviewed.
The facility's policy is to follow-up on all clients within thirty-days of discharge regardless of their discharge status.
Client #5 was admitted on November 21, 2024, and was discharged on January 3, 2025. The client record did not contain documentation of a follow-up contact.
Client #6 was admitted on November 23, 2024, and was discharged on January 6, 2025. The client record did not contain documentation of a follow-up contact.
This is a repeat citation from the February 5, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility shall maintain a complete client record which includes follow-up contact within 30 days of discharge from residential level of care, no matter the clients discharge status.
For the next 60 days the Clinical Director will audit five charts per week to ensure they include documentation of a follow-up contact within 30 days of a clients discharge from residential level of care, no matter the status of the discharge.
Ongoing: The Clinical Director will conduct quarterly chart audits to ensure follow-up contacts were made within 30 days of discharge from residential level of care, no matter the status of the discharge. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on the review of patient records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction was submitted to the Department for inspections occurring on February 5, 2024, and Febuary 10, 2023, addressing the requirement to follow-up with detox clients in accordance with the facility's policy.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to comply with a plan of correction that was approved by the
Department.
Over the next 90 days the Campus
Director will review the Plan of
Correction to ensure compliance.
Ongoing: The Campus Director will conduct
quarterly reviews of the Plan of Correction to ensure compliance. |