INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 9-12, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run, Inc. 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 10, 2009.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of employee personnel and training records, the facility failed to document monthly supervisory sessions for each new supervisor for the first six months of employment.
The findings include:
During the onsite licensing inspection of March 9-12, 2009 a review of employee # 21's training record indicated that no supervisory notes were documented for the initial six months of employment. This employee was hired 2/2/09. No notes were documented at the time of her record review on March 4, 2009.
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Plan of Correction
Employee #21 started at White Deer Run on 2/2/09. Supervision for the month of February was completed on 2/10/09, but was not forwarded to the QI Department for the staff training file in a timely manner. Supervision for the month of March was completed on 3/31/09. No later than April 27, 2009, supervision documents will be sent to the QI department and to the Director of Research and Development during the week the supervision is completed.
The Regional Clinical Director and Clinical Supervisors will continue to receive the "supervision due" list from the QI department at least every 2 weeks. Supervisions are to be submitted within the time frame specified. The Regional Administrator will review the list at least every 2 weeks for the 1st 3 months to ensure compliance with due dates and thereafter monthly. When supervisions do not occur within the prescribed time frame, the progressive disciplinary process will be used to reassert the expectation.
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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.
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Observations
Based on the review of employee personnel and training records, the facility failed to document periods of direct observation and close supervision for each counselor assistant as required.
The findings include:
During the onsite licensing inspection of March 9-12, 2009 employee supervision records were reviewed . No documentation of close supervision was documented for employee # 6, hired 2/19/09. No documentation of direct observation was on record for employee # 10, hired 6/10/08, who was a high school level counselor assistant. Employee # 12 was hired 2/24/09 and required close supervision , at the time of her personnel record review , no documentation of close supervision was documented. Employee # 19, promoted 3/31/08, needed weekly close supervision, the required one hour of direct observation per week was not documented.
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Plan of Correction
Employee #6, started employment at White Deer Run on 2/19/09 and separated employment on 3/25/09. Supervisions were completed for this employee on 2/23/09, 3/3/09, 3/12/09 and 3/16/09. The supervisions for 2/23/09 and 3/3/09 were not forwarded to the QI Department for the staff training file in a timely manner. While employee #6 no longer works at White Deer Run, the plan of correction to prevent future occurrences is that beginning no later than April 27, 2009, supervision documents will be sent to the QI department and to the Director of Research and Development during the week the supervision is completed.
The Regional Clinical Director and Clinical Supervisors will continue to receive the "supervision due" list from the QI department at least every 2 weeks. Supervisions are to be submitted within the time frame specified. The Regional Administrator will review the list at least every 2 weeks for the 1st 3 months to ensure compliance with due dates and thereafter monthly. When supervisions do not occur within the prescribed time frame, the progressive disciplinary process will be used to reassert the expectation.
Employee # 10, a high school level Counselor Assistant, was hired on 6/10/08. The Director of Quality & Nursing Services will 'add up' the supervision requirements which have been met and documented in her training file no later than 4/22/09. For any supervision requirements that are missing, the Clinical Supervisor for Employee #10 will provide the necessary supervision and documentation to be filed in her Training File beginning the week of 4/27/09, and concluding when the direct observation requirements have been met. The supervision requirements are:
A Counselor Assistant hired with only a high school diploma, GED equivalent, or a non-related degree, may counsel clients only in the presence of a trained counselor or clinical supervisor, for the first 3 months of employment.
In addition the supervisor must: (1) Co-sign all charting notes (2) Document a weekly clinical supervision session with the counselor assistant. (3) Document in the weekly clinical supervision session the number of group sessions and the number of individual sessions conducted by the CA, with the supervisor documenting, "I sat in on all of these sessions".
Following these 3 months of directly observing the interaction with patients, the CA is followed by Close Supervision every week, for the next 9 months.
The weekly close supervision log will be modified to include the number of group sessions and the number of individual sessions conducted by the Counselor Assistant with the supervisor or qualified designee documenting that all sessions were observed.
To ensure ongoing compliance, the Regional Clinical Director and Clinical Supervisors will continue to receive the "supervision due" list from the QI department at least every 2 weeks. Supervisions, including those specified as "high school level" are to be submitted within the time frame required. The Regional Administrator will review the list at least every 2 weeks for the 1st 3 months to ensure compliance with due dates and thereafter monthly. When supervisions do not occur within the prescribed time frame or format, the progressive disciplinary process will be used to reassert the expectation.
Supervision on employee #12 was completed on 3/2/09 and 3/9/09 but was not forwarded to the QI Department for the staff training file in a timely manner. No later than April 27, 2009, supervision documents will be sent to the QI department and to the Director of Research and Development during the week the supervision is completed.
The Regional Clinical Director and Clinical Supervisors will continue to receive the "supervision due" list from the QI department at least every 2 weeks. Supervisions are to be submitted within the time frame specified. The Regional Administrator will review the list at least every 2 weeks for the 1st 3 months to ensure compliance with due dates and thereafter monthly. When supervisions do not occur within the prescribed time frame, the progressive disciplinary process will be used to reassert the expectation.
Employee # 19 was promoted to a high school level Counselor Assistant on 4/7/08. The Director of Quality & Nursing Services will 'add up' the supervision requirements which have been met and documented in her training file no later than 4/22/09. For any supervision requirements that are missing, the Clinical Supervisor for Employee #10 will provide the necessary supervision and documentation to be filed in her Training File beginning the week of 4/27/09, and concluding when the direct observation requirements have been met. The supervision requirements are:
A Counselor Assistant hired with only a high school diploma, GED equivalent, or a non-related degree, may counsel clients only in the presence of a trained counselor or clinical supervisor, for the first 3 months of employment.
In addition the supervisor must: (1) Co-sign all charting notes (2) Document a weekly clinical supervision session with the counselor assistant. (3) Document in the weekly clinical supervision session the number of group sessions and the number of individual sessions conducted by the CA, with the supervisor documenting, "I sat in on all of these sessions".
Following these 3 months of directly observing the interaction with patients, the CA is followed by Close Supervision every week, for the next 9 months.
The weekly close supervision log will be modified to include the number of group sessions and the number of individual sessions conducted by the Counselor Assistant with the supervisor or qualified designee documenting that all sessions were observed.
To ensure ongoing compliance, the Regional Clinical Director and Clinical Supervisors will continue to receive the "supervision due" list from the QI department at least every 2 weeks. Supervisions, including those specified as "high school level" are to be submitted within the time frame required. The Regional Administrator will review the list at least every 2 weeks for the 1st 3 months to ensure compliance with due dates and thereafter monthly. When supervisions do not occur within the prescribed time frame or format, the progressive disciplinary process will be used to reassert the expectation.
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704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of employee training records, the facility failed to ensure that each clinical supervisor received the required 12 hours of annual training.
The findings include:
During the onsite licensing inspection of March 9-12, 2009, the training records of three clinical supervisors were reviewed. Employee # 4 had only 9 documented hours of training for the training year ended in December of 2008.
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Plan of Correction
Supervisor in question and all supervisors are required to complete monthly training opportunities through a combination of the Essential Learning website and semi-monthly and monthly PCB approved trainings in the Allenwood area to fulfill yearly requirements. The Director of Research and Development and the Clinical Director are responsible to review monthly compliance with the required trainings and training hours defined on each employees' Essential Learning website "transcript". Non-compliance will be addressed through weekly, monthly or quarterly supervision and the Progressive Disciplinary Process, when warranted. By April 15, 2009 all supervisors will be re-trained on the requirements and instructed to implement this action plan |
704.12(b) & (c) & (d) LICENSURE Counselor Asst/Exceptions
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(b) Counselor assistants. Counselor assistants may be included in determining FTE ratios when the counselor assistant is eligible for a caseload.
(c) Exemption for transitional living. Specific client/staff ratios are not required for transitional living facilities.
(d) Exceptions. A project director may submit to the Department a written petition requesting an exception to the client/staff and client/counselor ratios in this section. The petition shall describe how the characteristics of the program and its client mix support the request for the exception and shall be approved by the governing body. Granting the petition shall be at the discretion of the Department. Long-term residential facilities and halfway houses which include a client's participation in schooling or employment as part of a treatment day are examples when requests for exceptions will be considered.
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Observations
Based on the review of employee training records , the facility failed to properly document supervision of counselor assistants so that they could be counted in the FTE ratio.
The findings include:
During the onsite licensing inspection of March 9-23, 2009 the training and supervision records of fourteen counselor assistants were reviewed. Direct observation was required for each client counseling session conducted by counselor assistant # 14, who was a high school level assistant. No documentation of direct observation was included in the employee training record and no co- signatures by qualified staff were noted in the client record samples reviewed.
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Plan of Correction
Weekly direct and close supervision for high school level counselor assistants will identify in the supervisor notes the number of client contact hours for group and individual work as defined by the standard. Training with the clinical supervisors by the Director of Research and Development on the use of direct and close supervision for counselor assistants with high school diploma will occur to review the parameters of the standard by April 22, 2009. To ensure on-going compliance, random audits will be performed by the QI department for the next 3 months and report deficiencies to the Regional Administrator. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the physical plant inspection of 3/9/2009 the facility failed to ensure that all bathrooms were clean and functional at all times.
The findings include:
During the onsite licensing inspection of March 9-12, 2009 the physical plant was inspected. Medicine cabinets/vanities in building # 24 were made of metal and it was noted that the metal was rusted . Toothbrushes were stored in an unsanitary manner on rusted shelves or under sink cabinets and it was noted the bristles were not covered, presenting an infection control concern. Room # 205 in building # 1 had a leaky shower faucet. A light cover was missing in room # 207 in building # 1. Rooms # 205 and 207 also had worn caulking around the showers, with mildew noted in the caulking. In room # 1, building 25, mildew was noted in the shower area and there was damage to paint in the bathroom.
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Plan of Correction
During the week of the survey, the following items were repaired by the Maintenance Department: In building #24 all metal medicine cabinets were eliminated and replaced with mirrors. Plastic cases, in which to store toothbrushes, are provided to patients at admission. In building #1, room 205, the leaky shower has been repaired, room 207 the light cover was replaced and in both bathrooms the mildew was removed and new caulking was installed. Building #25, room 1, had the mildew removed and the damaged paint was repaired.
The Operations Director and Safety Officer will work in conjunction with the Maintenance Coordinator to develop a preventative maintenance plan to ensure that building fixtures and general maintenance is regularly assessed and upgraded as needed. This plan will be completed and implemented by April 30, 2009.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection of 3/12/2009 the facility failed to prohibit the use of space heaters in all buildings.
The findings include:
During the onsite licensing inspection of March 9-12, 2009 the detoxification unit was inspected. A space heater was present in one office on the counseling wing of the detoxification unit.
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Plan of Correction
The Operations Director contacted our HVAC vendor to install a "balancer" to evenly distribute heating and cooling to the areas of the building in which temperature has not been adequately maintained. Initial work was completed the week of March 30th with on-going service by the installer to evaluate and adjust the system as needed. The space heater has been removed and staff member was counseled on regulations regarding the use of portable heaters, and the safety department will monitor compliance during their monthly building surveillances beginning April 2009. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of agency fire drill logs the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
During the onsite licensing inspection of March 9-12, 2009, agency safety manuals and the fire drill log were inspected. No fire drills were documented during sleeping hours for the six month period between June, 2008 and December, 2008.
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Plan of Correction
On March 20, 2009, the Coordinator of Risk Management and Safety added an additional signature line to the fire drill sheet as a check and balance to ensure that at least 1 fire drill during sleeping hours is completed quarterly. Fire drills during sleeping hours will be reviewed beginning in April 2009 for accuracy and compliance at the monthly facility safety committee meeting. |
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 a review of the agency policy and procedure manual, interviews with administrative staff and a review of client records, the facility failed to document psychosocial evaluations for clients in the detoxification level of care in 14 client records.
The findings include:
Nineteen client records and the agency policy on psychosocial evaluations were reviewed and agency administrative and nursing staff were interviewed during the onsite licensing inspection of March 9-12, 2009. The agency policy stated that psychosocial evaluations are completed within 72 hours of the client's transfer to the rehabilitation program. Interviews with agency staff revealed that psychosocial evaluations were not done for detox unit clients unless the clients were to be involved only in the detox program. Reviews of client records # 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12 15, 16 and 17 demonstrated that no psychosocial evaluations were documented during the client's stay in the detox unit as required.
This is a repeat deficiency from the April 25, 2008 licensing inspection.
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Plan of Correction
All patients are interviewed at time of admission by the nursing staff and a thorough assessment is completed. Within 30 days, a section will be added, through approval by the forms committee, to the Nursing Assessment form for the inclusion of an assessment summary. Nurses will be trained by the Director of Nursing and the Director of Research and Development as to the impressions and conclusions required in this area. The Nurse Manager will review all Nursing Assessments for the first quarter, after the new procedure has been implemented, and randomly thereafter. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records during the licensing inspection of March 9 -12 , 2009, the facility failed to document personal histories to include family history, legal history, employment/vocational history, educational history, military history, recreational history and/or sexual history in twelve of nineteen applicable client records.
The findings include:
During the onsite licensing inspection of March 9- 12, 2009 nineteen records were reviewed. Twelve client records failed to document complete personal histories as follows: Client
records # 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 16 and 17 did not document family dynamics as part of the family history. Family histories were incomplete in 12 client records.
The employment history in client records # 2, 4, 5, 8, 9, 11, 14 and 17 documented only the client's most recent employment and did not document a complete employment history.
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Plan of Correction
By April 30, 2009 weekly trainings executed by the Clinical Supervisors, specific to the family history and work history sections of the bio-psycho social, will be initiated.
Within 60 days, the Regional Clinical Director with the support of the Director of Research and Development will select members from the clinical team to participate on a Clinical Care Committee for the facility and region. This group will meet monthly and review results of chart audits. The committee will also identify training need areas, and recommend trainings for select staff as identified through the record audits.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates in accordance with written agency policy.
The findings include:
Nineteen client records were reviewed during the onsite licensing inspection of March 9- 12, 2009. Five of these records required fifteen day treatment plan updates. One of five records reviewed lacked documentation of the updated treatment plans, specifically client record # 2.
Client record # 2 had a treatment plan formulated on 9/12/08. The client remained active in the program until the time of discharge on 10/01/08. No treatment plan update was documented.
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Plan of Correction
Clinical Supervisors will provide training specific to the need for treatment plan updates to be completed within 15 days of the initiation of the treatment plan. This training will be started in 15 days and monitored through weekly, monthly and quarterly supervisions beginning May 1, 2009. This will be documented in group supervision notes by the Clinical Supervisors and audited through the Clinical Care review process.
Within 60 days, the Regional Clinical Director with the support of the Director of Research and Development will select members from the clinical team to participate on a Clinical Care Committee for the facility and region. This group will meet monthly and review results of chart audits. The committee will also identify training need areas, and recommend trainings for select staff as identified through the record audits.
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