INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 7-8, 2022, 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, 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:
|
Plan of Correction
|
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
|
Observations
Based on a review of seven detox client records, the facility failed to provide a complete client record, which is to include a discharge summary in three of the three applicable client records reviewed. Client #5 was admitted on January 5, 2022 and was discharged on January 9, 2022. The client record did not contain documentation that a discharge summary was completed. Client #6 was admitted on February 23, 2022 and was discharged on February 28, 2022. The client record did not contain documentation that a discharge summary was completed. Client #7 was admitted on February 24, 2022 and was discharged on March 1, 2022. The client record did not contain documentation that a discharge summary was completed.These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Medical Records Department will conduct discharge chart audits 7 days post discharge and report missing documentation to clinical supervisors.
Clinical Supervisors will review with the counselors any non-compliant charts and will conduct ongoing supervision, and if needed employee improvement sessions with those Counselors that may require additional training.
Residential D & A Chart Audit form has been revised to include the above criteria and those outlined in Policy 709.53 Multi-Disciplinary Discharge Summary.
|
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
|
Observations
Based on a review of seven detox client records, the facility failed to provide a complete client record, which is to include follow up information in three of the three applicable client records reviewed. Client #5 was admitted on January 5, 2022 and was discharged on January 9, 2022. The client record did not contain documentation that follow up information was completed. Client #6 was admitted on February 23, 2022 and was discharged on February 28, 2022. The client record did not contain documentation that follow up information was completed.Client #7 was admitted on February 24, 2022 and was discharged on March 1, 2022. The client record did not contain documentation that follow up information was completed.These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
An additional staff member was hired to focus on all follow-up calls to aftercare agencies or in the event an individual refused aftercare to the individual. Staff member is keeping a spreadsheet to ensure all discharged patients and/or aftercare agencies received a follow-up call.
All staff conducting follow up calls have been re-trained on and reviewed the follow-up policy. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
|
Observations
Based on an observation of medication administrations during the physical plant inspection, the facility failed to ensure four clients ingested the medication following administration before they left the medication window. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Nursing staff will conduct thorough mouth checks at all medication times by asking patient to take their medication, drink water, then the nurse will do a thorough mouth inspection, including asking the patient to speak back by stating their first name, last initial.
Procedure and expectations will be reviewed with patient by nurse at time of medication consent.
Director of nursing will do an in-service with all nursing staff to review procedure, expectations and will be responsible for ensuring the plan is implemented and followed through by doing random checks weekly during medication time to ensure compliance.
|
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 seven inpatient client records, the facility failed to provide a complete client record, which is to include discharge summaries in two of the three applicable client records. Client #12 was admitted on September 22, 2021 and was discharged on September 26, 2021. The client record did not contain documentation that a discharge summary was completed. Client #13 was admitted on December 22, 2021 and was discharged on February 9, 2021. The client record did not contain documentation that a discharge summary was completed. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Medical Records Department will conduct discharge chart audits 7 days post discharge and report missing documentation to clinical supervisors.
Clinical Supervisors will review with the counselors any non-compliant charts and will conduct ongoing supervision, and if needed employee improvement sessions with those Counselors that may require additional training.
Residential D & A Chart Audit form has been revised to include the above criteria and those outlined in Policy 709.53 Multi-Disciplinary Discharge Summary.
|
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
|
Observations
Based on a review of seven inpatient client records, the facility failed to provide a complete client record, which is to include follow up information in two of the three applicable client records. Client #12 was admitted on September 22, 2021 and was discharged on September 26, 2021. The client record did not contain documentation that follow up information was completed. Client #13 was admitted on December 22, 2021 and was discharged on February 9, 2021. The client record did not contain documentation that follow up information was completed.These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
An additional staff member was hired to focus on all follow-up calls to aftercare agencies or in the event an individual refused aftercare to the individual. Staff member is keeping a spreadsheet to ensure all discharged patients and/or aftercare agencies received a follow-up call.
All staff conducting follow up calls have been re-trained on and reviewed the follow-up policy. |