D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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WHITE DEER RUN OF LANCASTER
53-55 NORTH WEST END AVENUE
LANCASTER, PA 17603

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Survey conducted on 03/12/2015

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on March 12, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run of Lancaster 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
704.6(a) LICENSURE Clinical Supervisor Qualifications 704.6. Qualifications for the position of clinical supervisor. (a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
Observations Based on a review of the Staffing Requirements Facility Summary Report forms for all facilities within the drug and alcohol treatment project, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both. The findings include: The Staffing Requirements Facility Summary Report forms for the drug and alcohol treatment project's seventeen facilities were reviewed on March 2, 2015. The project employs a total of 106 full-time counselors and counselor assistants. This number of full-time counselors and counselor assistants would require a minimum of 13 full-time clinical supervisors. The project currently employs 8 full-time clinical supervisors, as of March 2, 2015. The findings were reviewed with facility staff during the licensing process.	Plan of Correction The Director of Quality Management, along with the Executive Director, will ensure there is one full-time clinical supervisor for every eight full-time counselors and counselor assistants. Caseloads will be redistributed by July 1, 2015 so that clinical supervisors who carry a caseload fall within the guidelines of chapter 704.6. Facility directors and clinical supervisors will be re-educated by the Quality Management Department on permissible case load sizes for each level of care. Compliance will be accomplished by the facility director, along with the clinical supervisor(s), monitoring the number of full-time counselors vs. clinical supervisors on a quarterly basis.
704.11(c)(3) & (4) LICENSURE Training types and amounts 704.11. Staff development program. (c) General training requirements. (3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff. (4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
Observations Based on review of personnel records and the Staffing Requirements Facility Summary (SRFSR) report, the facility failed to ensure that at least one-half of all training was provided by trainers not directly employed by the project in one of four records reviewed. The findings include: The SRFSR was reviewed on March 2, 2015 and re-reviewed on March 12, 2015, as well as four personnel records for documentation that at least one-half of all training was provided by trainers not directly employed by the project during the facility's January 1, 2014 to December 31, 2014 training year. The SRFSR and the training certificates located in the personnel file indicated that more than one-half of training completed by employee #3 was provided by trainers directly employed by the project. Employee #3 was hired as a counselor on June 6, 2011. The SRFSR indicated that employee # 4 received a total of 34 hours of training during the 2014 training year. However, 31.5 hours were provided by facility staff and 2.5 hours were provided by an outside trainer. Upon further review of the personnel file for employee #4 confirmed that the employee did receive 31.5 hours provided by facility staff and 2.5 hours provided by outside trainer. These findings were reviewed with facility staff during the licensing process.	Plan of Correction One Half of all staff training hours will be provided by trainers not directly employed by the project. Clinical supervisor will ensure this is adhered to. She has been educated on this requirement by QM. The QM department will send out a quarterly report that lists staff and the trainings they have taken. Clinical supervisors will be responsible for assuring that staff have the appropriate type of training hours. The report will be reviewed with counselors in supervisions sessions.
709.28(c) LICENSURE Confidentiality 709.28. Confidentiality. (c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
Observations Based on a review of client records, the facility failed to document a completed informed and voluntary consent from the client prior to the disclosure of information in one of eleven client records. The findings included: Eleven client records requiring a completed informed and voluntary consent from the client prior to the disclosure of information were reviewed on March 12, 2015. The facility failed to ensure the documentation of a completed informed and voluntary consent from the client prior to the disclosure of information in client #4's record. Client #4 was admitted to treatment on February 23, 2015 and was still an active client at the time of the on-site inspection. There was a release of information form to a hospital that was signed on 02/23/15, but did not include the specific information to be released. Additionally, there was a second release of information to a pharmacy that was signed on 02/23/15 that did not include the specific information to be released. These findings were reviewed with the facility staff during the licensing process.	Plan of Correction Consents will be completed in their entirety. Facility Director will re-educate staff on the proper completion of consents. Medical Records Technician will conduct reviews of all admissions for that day to ensure consents are done properly or corrected immediately to prevent violations of confidentiality. Ongoing chart audits by Nurse Manager will be conducted to ensure compliance.
709.53(a) LICENSURE Complete Client Record 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:
Observations Based on a review of client records, the facility failed to document a complete client record on an individual, which includes documentation of progress notes, aftercare plans, and discharge summaries in five of eleven client records reviewed. The findings include: Eleven client records requiring a complete client record on an individual were reviewed on March 12, 2015. The facility did not provide a complete client record for clients # 2, 3, 7, 8, and 9. Client #2 was admitted to treatment on February 13, 2015 and was still an active client at the time of the on-site inspection. The facility failed to include documentation of progress notes that were recorded on the client's record of service. Progress notes for 02/19/15, 02/20/15, 02/21/15, 02/22/15, 02/23/15, 02/24/15, 02/26/15, 02/27/15, 02/28/15, 03/01/15, 03/02/15, 03/03/15, 03/05/15, 03/07/15, 03/08/15, and 03/09/15 were missing from the client record. Client #3 was admitted to treatment on February 13, 2015 and was still an active client at the time of the on-site inspection. The facility failed to include documentation of progress notes that were recorded on the client's record of service. Progress notes for 02/14/15, 02/15/15, 02/17/15, 02/18/15, 02/19/15, 02/21/15, 02/22/15, 02/23/15, 02/28/15, 03/01/15, 03/02/15, 03/05/15, 03/06/15, 03/07/15, 03/08/15, and 03/09/15 were missing from the client record. Client #7 was admitted to treatment on February 02, 2015 and was discharged on March 10, 2015. The facility failed to include documentation of progress notes that were recorded on the client's record of service. Progress notes for 02/13/15, 02/14/15, 02/15/15, 02/16/15, 02/17/15, 02/18/15, 02/19/15, 02/21/15, 02/22/15, 02/23/15, 02/26/15, 02/27/15, 03/01/15, and 03/02/15 were missing from the client record. Additionally, the facility failed to include documentation of an aftercare plan. Client #8 was admitted to treatment on December 19, 2014 and was discharged on January 12, 2015. The facility failed to include documentation of progress notes that were recorded on the client's record of service. Progress notes for 12/21/14, 12/22/14, 12/23/14, 12/25/14, 12/26/14, 12/27/14, 12/28/14, 12/30/14, 01/01/15, 01/02/15, 01/03/15, 01/05/15, 01/06/15, 01/07/15, 01/08/15, 01/09/15, 01/10/15, and 01/11/15 were missing from the client record. Additionally, the facility failed to include documentation of a discharge summary. Client #9 was admitted to treatment on January 27, 2015 and was discharged on February 16, 2015. The facility failed to include documentation of progress notes that were recorded on the client's record of service. Progress notes for 02/01/15, 02/05/15, 02/06/15, 02/07/15, 02/08/15, 02/10/15, 02/11/15, 02/12/15, 02/13/15, 02/14/15, and 02/15/15 were missing from the client record. These findings were reviewed with facility staff during the licensing process.	Plan of Correction Complete client records will include a progress note for every group documented on the record of service. For those records that are closed, discharge summary and aftercare follow up will be completed and filed. Clinical Supervisor will re-educate clinical staff on the standards for a complete client record. Clinical Supervisor will complete quality review chart audits weekly so that deficiencies can be addressed in a timely manner. Medical Records Technician will review all discharged charts weekly to ensure all paperwork has been filed.