This report is a result of an onsite follow-up inspection regarding the plans of correction for the March 12, 2009 licensure renewal inspection. The follow-up inspection was conducted on June 9, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 July 14, 2009.
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Plan of Correction
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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 and was cited at the annual licensing inspection of 3/12/09. This area was deemed to be out of compliance at the June 9, 2009 follow up inspection.
The findings included:
An interview was held with the Nursing Supervisor and the Quality Assurance coordinator during a follow up inspection on 6/9/09. They stated that the corrections to the psychosocial evaluations had not yet been implemented due to delays in the administrative review process for the approval of new forms. All records of clients in detox since the stated correction date of 4/9/09 have failed to document a psychosocial evaluation.
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Plan of Correction
It is the current policy to complete a Psychosocial Assessment for all patients admitted for treatment; for 'detox only patients' the Nursing Assessment serves at the Psychosocial Assessment. The policies and procedures describing this practice were reviewed and approved by the Department a number of years ago. For detox patients who will transfer to rehab, a Nursing Assessment is also completed within 24 hours of admission to the Detox unit.
For detox patients being transferred to the rehabilitation program, the 'Intake & Admissions' policy requires that a Psychosocial Assessment must be completed within 72 hours of admission to the rehabilitation unit, and a Diagnostic Summary (Addendum I to the Psychosocial Assessment) within 72 hours of transfer into the rehabilitation unit.
The former 'Detox only Clinical Addendum' is now completed within 48 hours of admission for all detox patients. The Addendum is completed by qualified nursing or clinical staff. The facility cannot be responsible for completing an Addendum if a patient chooses to leave the facility AMA before it is completed.
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