INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on December 30, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, White Deer Run Inc. - 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:
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Plan of Correction
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705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
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Observations
Based on a physical site inspection, the facility failed to maintain storage area for clothing in good repair. Rooms 2E, 2D, two in 3B, 2C, and two in 3A were missing handles on dressers.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will ensure storage dressers for clothing in rooms 2E,2D, two in room 3B,2C and two in 3a
will have missing handles replaced.
On regular monthly walk through client dressers will be examined for
missing handles or any other safety/quality concerns.
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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 a physical site inspection, the facility failed to maintain bathrooms in a clean and sanitary manner. The first bathroom located on the 3rd floor had a dirty shower.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will ensure cleaning staff are properly trained and monitored for how to clean bathroom areas to prevent the spread of infection and ensure cleanliness of patient bathrooms.
Once a month during walk through bathroom areas will be inspected for cleanliness. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure exits were unobstructed. There was a blanket on the 2nd floor back exit. The 3rd floor emergency exit was blocked with a vacuum and a chair. The first-floor emergency exit steps was covered with a blue frayed blanket causing a tripping hazard.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director has removed all obstructions from exits throughout the facility.
Once a month walk throughs will be completed to monitor for compliance of unobstructed exits. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form in five out of nine records reviewed.
Client #2 was admitted on September 11, 2020 and discharged on September 27, 2020. A consent to release form, dated September 11, 2020 to parole did not indicate what information could be released.
Client #3 was admitted on September 1, 2020 and discharged on October 1, 2020. A consent to release dated September 22, 2020 to a government agency failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b). The consent permitted release of psychiatric evaluation, history and physical, discharge summary, discharge instructions, biopsychosocial/diagnostic, and continuing care plan. A second consent to a family member dated September 7, 2020 did not indicate what information could be released.
Client #5 was admitted on June 7, 2020 and discharged on June 12, 2020. Two consent forms to a family member and a government agency did not indicate what information could be released.
Client #7 was admitted on December 7, 2020 and was still active at the time of the inspection. A consent form dated December 7, 2020 to a government agency did not indicate what information could be released.
Client #8 was admitted on November 24, 2020 and was still active at the time of the inspection. Two consent forms dated December 17, 2020 to an employer failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b). One consent permitted prognosis, nature of project, brief description of progress of client, and client relapsed and frequency. A second consent form permitted emergency information limited to nature of emergency, course of action and resolution/outcome.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Quality Improvement Manager will conduct a mandatory Confidentiality/Consent Training to all nursing and admission staff. Evidence of attendance will be maintained in the facility training files. This will take place by March 30, 2021 and will include all staff hired within the past year.
Random chart reviews will be conducted on a monthly basis to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director. Follow up and further training will be conducted with responsible staff should a record be out of compliance with 709.28 (c)(2).
Client #2, 3, 5 and 7 consents are unable to be corrected due to the patients have already left treatment.
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709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form in one out of nine records reviewed.
Client #3 was admitted on September 1, 2020 and discharged on October 1, 2020. A consent to release information form dated September 1, 2020 to a government agency indicated "other" for purpose without specifying the additional purpose.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Quality Improvement Manager will conduct a mandatory Confidentiality/Consent Training to all nursing and admission staff. Evidence of attendance will be maintained in the facility training files. This will take place by March 30, 2021 and will include all staff hired within the past year.
Random chart reviews will be conducted on a monthly basis to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director. Follow up and further training will be conducted with responsible staff should a record be out of compliance with 709.28 (c)(3).
Client #3 consent is unable to be corrected due to the patient has already left treatment.
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709.28 (c) (6) 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 must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on the review of client records, the facility failed to document an expiration date on a consent to release information form in one out of nine records reviewed.
Client #8 was admitted on November 24, 2020 and was still active at the time of the inspection. A consent form dated December 13, 2020 to a family member did not indicate an expiration date.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Quality Improvement Manager will conduct a mandatory Confidentiality/Consent Training to all nursing and admission staff. Evidence of attendance will be maintained in the facility training files. This will take place by March 30, 2021 and will include all staff hired within the past year.
Random chart reviews will be conducted on a monthly basis to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director. Follow up and further training will be conducted with responsible staff should a record be out of compliance with 709.28 (c)(6).
Client #8 consent is unable to be corrected due to the patient has already left treatment.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to indicate whether a copy was offered to the client in one out of nine records reviewed.
Client #8 was admitted on November 24, 2020 and was still active at the time of the inspection. There were four consents without the required information. One was dated December 7, 2020 to another treatment facility. The second was to a family member dated December 1, 2020. Third and fourth were dated November 24, 2020 to a hospital and a government agency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Quality Improvement Manager will conduct a mandatory Confidentiality/Consent Training to all nursing and admission staff. Evidence of attendance will be maintained in the facility training files. This will take place by March 30, 2021 and will include all staff hired within the past year.
Random chart reviews will be conducted on a monthly basis to monitor for compliance. Results will be shared with the Quality Improvement Manager and Facility Director. Follow up and further training will be conducted with responsible staff should a record be out of compliance with 709.28 (d).
Client #8 consent is unable to be corrected due to the patient has already left treatment.
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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.
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Observations
Based on a review of client records, the facility failed to include a discharge summary in two out of five records reviewed.
Client #1 was admitted on July 1, 2020 and discharged on July 27, 2020.
Client #2 was admitted on September 11, 2020 and discharged on September 27, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will ensure there is a discharge summary completed and placed in the client record within seven days of a client's discharge from the facility.
Clinical Supervisor will audit charts monthly to ensure ongoing compliance with the regulation.
Discharge Summaries will be completed on client #1 and #2 and placed in the client record.
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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.
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Observations
Based on a review of client records, the facility failed to include follow-up information in two out of five records reviewed.
Client #2 was admitted on September 11, 2020 and discharged on September 27, 2020.
Client #3 was admitted on September 1, 2020 and discharged on October 1, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will ensure there is a follow up form completed and placed in the client record within the seven days of a client's discharge from the facility.
Clinical Supervisor will check weekly follow up calls are being documented weekly to ensure compliance with the regulation.
Follow ups will be completed on Client #2 and #3.
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document work done by the client in his/her treatment plan in five out of five records reviewed.
Client #2 was admitted on September 11, 2020 and discharged on September 27, 2020.
Client #3 was admitted on September 1, 2020 and discharged on October 1, 2020.
Client #6 was admitted on September 23, 2020 and discharged on October 16, 2020.
Client #7 was admitted on December 7, 2020 and was still active at the time of the inspection.
Client #8 was admitted on November 24, 2020 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In the event house chores become therapeutic and part of the client's treatment goals, the clinician's will ensure there is a treatment goal listed on the client's treatment plan for the chores.
Clinical Supervisor will monitor for compliance in monthly chart audits.
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