INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 28, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, White Deer Run, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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 policies & procedures, client records and staff interviews, the facility failed to document written procedures for the manangement of treatment/rehabilitation services for clients which included the return of client belongings, to persons other than the client, upon discharge.
The policy and procedure manual was reviewed on March 28, 2024. The policy and procedure for the return of client belongings was requested. There are documents and procedures for the return of items to the client; however, there are no procedures documented for the return of client belongings to other persons if the client is unavailable.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
QI Director has updated the search & contraband policy and procedure to include dropping off of and the return of client belongings, to persons other than the client, upon discharge. It is now required that if a person other than the client is retrieving the client's belongings from the facility that there be written consent in the chart for the person delegated to retrieve the belongings, additionally, facility staff will check photo identification of the person retrieving the belongings and when possible have the person retrieving the belongings sign the clients search sheet.
Supervisors and Security staff will be trained on this updated protocol by 4/20/24.
Security supervisor will create a log book that will be used to record transactions between items dropped off or retrieved from the facility. The log book will record whether there is consent from the client, documented identification check of the person dropping off or retrieving the items, time, client name, name of person dropping off/retrieving items, comments identifying drop off/retrieving items and if known what items are being dropped off/retrieved and a receipt option.
Security supervisor will review this log book with security staff and supervisors by 5/8/24. Security supervisor will monitor the log book entries bi-weekly.
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of policy and procedures, client records and staff interview, the facility failed to maintain the confidentiality of client identity.
Client #1 was admitted on January 26, 2024 and medically discharged on February 10, 2024. There was one signed family consent to release client identifying information documented in client record #1. A person, other than the family member authorized, reported to the facility on February 12, 2024 and asked for client's belonings. Facility staff provided the client's belongings to the person at that time. There was no signed consent to release information for this person in the clients record and the person's identity is unknown at this time as no identification or verification was documented.
These findings were reviewed with facility staff during the investigation proces.
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Plan of Correction
QI Director has updated the search & contraband policy and procedure to include dropping off of and the return of client belongings, to persons other than the client, upon discharge. It is now required that if a person other than the client is retrieving the client's belongings from the facility that there be written consent in the chart for the person delegated to retrieve the belongings, additionally, facility staff will check photo identification of the person retrieving the belongings and when possible have the person retrieving the belongings sign the clients search sheet.
Supervisors and Security staff will be trained on this updated protocol by 4/20/24.
Security supervisor will create a log book that will be used to record transactions between items dropped off or retrieved from the facility. The log book will record whether there is consent from the client, documented identification check of the person dropping off or retrieving the items, time, client name, name of person dropping off/retrieving items, comments identifying drop off/retrieving items and if known what items are being dropped off/retrieved and a receipt option.
Security supervisor will review this log book with security staff and supervisors by 5/8/24. Security supervisor will monitor the log book entries bi-weekly.
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709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of policy and procedure, client records and staff interviews, the facility failed to follow their medication administration policies.
The facility policy states that a complete and accurate list of pre-admission medication will be obtained and documented for each client. That list is then used when writing medication orders and the physician will determine the appropriateness of each medication being prescribed to the client.
Client #1 was admitted on January 26, 2024 and medically discharged on February 10, 2024. The client presented to the facility with multiple medications. The physician completed a history and physical exam on January 24, 2024. All but one of the client's medications were addressed in the documentation and orders. There was no documentation of a determination of the appropriateness or need for this psychiatric medication by the physician and no order was written. The client was precribed a daily dose of 550 mg of this medication prior to admission at the facility. The client was not administered this medication until February 9, 2024.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
The admitting nurse will thoroughly investigate the patients current and past medication history at the time of admission. If for any reason the patient is unsure of current medications that they may be on, the admitting nurse will ask the patient what pharmacy they use to fill their medications. The admitting nurse will confirm questionable medications with the patients pharmacy. The admitting nurse will inform the on call provider of the patients current medications. The provider will thoroughly review and reconcile the patients medication at the time of the History and Physical. The provider will review the patients current medical history obtained during the Nursing Assessment. The provider will make sure that all appropriate medications are ordered prior to the end of the History and Physical
Director of nursing will monitor by conducting 10 record reviews weekly.
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709.52(e)(2) LICENSURE Psychiatric supt serv
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(2) Psychiatric.
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Observations
Based on a review of client records and staff interviews, the facility failed to assist the client in obtaining psychiatric services when necessary.
Client #1 was admitted on January 26, 2024 and medically discharged on February 10, 2024. The client was prescribed a psychiatric medication that was being taken prior to admission at the facility. The medication was noted on the history and physical completed by the physician on January 27, 2024; however, that physician did not write an order for the client to continue being administered the medication and did not documented why it was not being ordered. A box was checked on the physical form stating that a consult should be made to psychiatry; however, the client did not meet with the psychiatrist until February 1, 2024. Even though the client was seen by the psychiatrist on February 1, 2024, the medication was not ordered at that time due to the psychiatrist not having access to the client's electronic chart. This medication was not ordered and administered to the client until February 9, 2024.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
All patients with a mental health disorder diagnosis or report a mental health condition will be seen by a member of the psychiatry team for their initial psychiatric evaluation within 72 hours of admission in rehab. During this psychiatric evaluation a secondary medication reconciliation of past and current medication will be obtained. The psychiatry provider will review these medications with the patient and confirm accuracy.
The psychiatry will prescribe the appropriate medications and obtain written consent from the patient. In the case of power or internet services being down, WDR has secondary internet provider; a secondary internet provider in contract process to serve as back up internet when primary failure occurs. Until secondary internet provider is approved; provider conducting H&P will communicate directly to nursing staff to place patient on psychiatric check list, however, if there is concern with psychiatric medication continuance on admission, provider will directly communicate with psychiatric team the urgency of need for session and medication reconciliation.
Director of nursing will monitor by conducting 10 record reviews weekly.
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