D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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WHITE DEER RUN, INC.
360 WHITE DEER RUN ROAD
ALLENWOOD, PA 17810

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Survey conducted on 02/28/2024

INITIAL COMMENTS
This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on February 27 & 28, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, 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:	Plan of Correction
704.9(c) LICENSURE Supervised Period 704.9. Supervision of counselor assistant. (c) Supervised period. (1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment. (2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment. (3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment. (4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment. (5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
Observations Based on a review of thirty personnel records, the facility failed to ensure that nine counselor assistants were counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.Employee #22 was hired on March 21, 2023 as a counselor assistant and was still employed in that position at the time of the inspection. Employee #22 has an associate degree and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for the first nine months of employment. Employee #22 did not receive direct observation for the weeks of April 3, 10, 17. 24, May 1, 8, 15, 22, 29, June 5, 12, 19, 26, July 10, 17, 24, 31, August 7, 14, 21, 28, September 4, 11, 18, 25, October 2, 9, 30, November 6, 13, 20, 27, and December 4, 11, 18 and 25, 2023. Employee #22 did not have formal documented case review the weeks of August 28, October 16 and 23, 2023. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Employee #23 was hired on August 8, 2023 as a counselor assistant and was still employed in that position at the time of the inspection. Employee # 23 has an associate degree and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for the first nine months of employment. Employee #23 did not receive direct observation for the weeks of August 14, 21, 287, September 4, 11, 18, 25, October 2, 9, 16, 23, 30, November 6, 13, 20, 27, December 4, 11, 18 and 25, 2023 and January 1, 8, 15 and 22, 2024. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Employee #24 was hired on October 17, 2023 as a counselor assistant and was still employed in that position at the time of the inspection. Employee #24 has a bachelor ' s degree without the one-year experience and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for the first six months of employment. Employee #24 did not receive direct observation for the weeks of November 13, December 18, 25, 2023, and January 8, 15, and 22, 2024. Employee #24 did not receive formal documented case review the weeks of October 30, November 6, 27, December 4, 11, 2023 and January 1, 2024. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Employee #25 was hired on May 22, 2023 as a counselor assistant and was still employed in that position at the time of the inspection. Employee #25 has a bachelor ' s degree without the one-year experience and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for the first six months of employment. Employee #25 did not receive direct observation the weeks of June 12, 26, July 3, 10, 24, 31, August 7, 14, 21, 28, September 4, 11, 18, 25, October 2, 9, 16, 23, 30, November 6, 13, and 20, 2023. Employee # 25 did not have formal documented care review the weeks of June 7, 26, August 21, September 4, 11, and 18, 2023. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Employee #26 was hired on November 28, 2023 as a counselor assistant and was still employed in that position at the time of the inspection. Employee #26 has a bachelor ' s degree without the one-year experience and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for the first six months of employment. Employee #26 did not receive direct observation the weeks of December 4, 11, 18, and 25, 2023 and January 1, 8, 15. 22 and 29, 2024. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Employee #28 was hired on October 2, 2023 as a counselor assistant and was still employed in that position at the time of the inspection. Employee #28 has a bachelor ' s degree without the one-year experience and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for the first six months of employment. Employee #28 did not receive direct observation the weeks of October 16, 23, 30, November 6, 13, 27, December 4, 18, and 25, 2023 and January 1 and 15, 2024. Employee #28 did not receive formal documented case review the weeks of October 12, November 20 and December 11, 2023. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Employee #29 was hired on October 17, 2023 as a counselor assistant and was still employed in that position at the time of the inspection. Employee # 29 has an associate degree and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for the first nine months of employment. Employee #29 did not receive direct observation the weeks of November 20, 27, December 4, 11, 18, and 25, 2023 and January 1, 2024. Employee #29 did not have formal documented case review the weeks of November 13 and 20, 2023. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Employee #30 was hired on May 16, 2023 as a counselor assistant and was still employed in that position at the time of the inspection. Employee #30 has a high school diploma and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first three months of employment and close supervision for the next nine months of employment. Employee #30 did not receive direct observation the weeks of May 22, 29, June 5, 12, 19, 26, July 3, 10, 17, 24, 31, August 7, 14, 21, 28, September 4, 11, 18, 25, October 9, 16, 23, 30, November 6, 13, 20, 27, December 4, 11, 18, and 25, 2023 and January 1, 8, 15 and 22, 2024. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . This is a repeat citation from the March 24, 2023 licensing inspection.This finding was reviewed with facility staff during the licensing process.	Plan of Correction 1. We have revised our weekly Counselor Assistant supervision form to explicitly include two additional sections for close supervision: a. Minimum 1 hour case review to include patient ID number(s) and brief summary of the case review content. b. Minimum 1 hour direct observation of a group or individual session to include patient ID number(s) and brief summary of the co-facilitated session. c. These close supervisions will be in compliance with the required time periods based on the counselor assistants credentials (i.e., 9 months for Associates, 6 months for Bachelors and 3 months for Masters, etc) and the positive assessment documentation. d. The close supervisions will be conducted by qualified counselors and clinical supervisors each week. 2. The same counselor assistant supervision form as noted in #1 above, also has provisions for High School/GED level and non-qualifying degree counselor assistants so that all supervision will be direct and documented weekly. 3. The Unit supervisor will use a spreadsheet to track each counselor assistant under close and direct supervision and will document the weekly supervision on the revised form starting 3/18/24. 4. Unit supervisors will turn in the spreadsheet weekly to the Clinical Director and Assistant Clinical Director who will ensure the supervisions are completed timely and correctly as required by the regulations. 5. On 1/3/24, the facility CEO, submitted a letter to DA, licensuredivision indicating our intent to utilize Senate Bill 941 (revisions to Act 66, 2023 staffing flexibilities) allowing one qualified staff to supervise up to three counselor assistants. After DDAP released Licensing Alert 03-2024, the facility CEO made the request official on 3/8/24 by sending the required form of intent to DA, licensuredivision via email. In compliance with that Act, we will not exceed 3 counselor assistants per qualified counselor/supervisor.
704.11(f)(2) LICENSURE Trng Hours Req-Coun 704.11. Staff development program. (f) Training requirements for counselors. (2) Each counselor shall complete at least 25 clock hours of training annually in areas such as: (i) Client recordkeeping. (ii) Confidentiality. (iii) Pharmacology. (iv) Treatment planning. (v) Counseling techniques. (vi) Drug and alcohol assessment. (vii) Codependency. (viii) Adult Children of Alcoholics (ACOA) issues. (ix) Disease of addiction. (x) Aftercare planning. (xi) Principles of Alcoholics Anonymous and Narcotics Anonymous. (xii) Ethics. (xiii) Substance abuse trends. (xiv) Interaction of addiction and mental illness. (xv) Cultural awareness. (xvi) Sexual harassment. (xvii) Developmental psychology. (xviii) Relapse prevention. (3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
Observations Based on a review of the Staffing Requirements Facility Summary Report and thirty personnel records, the facility failed to document the completion of 25 clock hours of annual training required for one counselor.Employee #18 was hired as a counselor on September 7, 2021 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2023 through December 31, 2023. Employee # 18's record only document 20 hours and 30 minutes of annual training for the training year reviewed. This finding was reviewed with facility staff during the licensing process.	Plan of Correction 1. The QI director, will track all direct care staff for training hours throughout the year and will send monthly updates to clinical supervisors to inform them of their staff's training hours status and list of required training topics that remain unsatisfied. 2. The Clinical Director and the Assistant Clinical Director will review the status of each direct care staff at the monthly supervisor meeting and address those supervisors who have staff who have not made progress since the prior month at getting their required training hours. 3. If by the start of the third quarter of the year, any direct care staff have not made good progress at obtaining their required training hours, the Clinical Supervisor in conjunction with the Clinical Director and HR Director will initiate the disciplinary process with that staff member and will require a schedule of trainings that will satisfy the requirements no later than the 11th month of the year. 4. The QI Director, will escalate to the CEO, any staff who show no progress month over month so that further action is assured.
709.53(a)(10) LICENSURE Discharge Summary 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: (10) Discharge summary.
Observations Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in three out of four applicable records reviewed. Per the facility ' s policy and procedure manual the discharge summary is to be completed within seven days of discharge. Client #9 was admitted on December 12, 2023 and discharged on January 9, 2024. A discharge summary was due no later than January 16, 2024; however, it was not completed until February 24, 2024. Client #10 was admitted on July 8, 2023 and discharged on August 2, 2023. A discharge summary was due no later than August 9, 2023; however, it was not completed until August 17, 2023. Client #11 was admitted on August 9, 2023 to the detox level of care and discharged on August 16, 2023 and was stepped down to the residential level of care on August 16, 2023 and discharged on September 13, 2023. There was no documentation that a discharge summary was completed. These findings were reviewed with facility staff during the licensing process.	Plan of Correction 1. The Medical Records Director and her staff, conduct audits on 100% of closed charts. In prior years, her audits looked at Discharge Summaries on day 8 post discharge. By this time, it is too late to comply with the requirement to complete all discharge summaries by day 7 post discharge. The audit process has changed to an audit check day 4 post discharge effective 3/11/24. 2. The Medical Records Director will provide a copy of every chart audit result to the clinical supervisor, Clinical Director, and Assistant Clinical Director. The clinical supervisor will meet with the primary counselor to ensure the DC Summary is completed no later than day 7 post discharge and will report the outcome back to the Clinical Director and Assistant Clinical Director. 3. The clinical supervisors will keep a running list of discharged patients on their daily census form and each day they will check the DC Summary status of those discharged patients who are in the 1-7 day post discharge period and will review this list in their morning huddle to assign completion of those summaries to be completed before the end of day 7. 4. If the primary counselor is unable to complete the DC Summary by the end of day 7 for any reason, the Clinical Supervisor is responsible to complete the summary by the end of day 7. 5. The Clinical Director and Assistant Clinical Director will review the status of DC Summaries every morning (Monday through Friday) in the morning flash meeting to ensure no Discharge Summary is late past day 7.