INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 23, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Perspectives At White Deer Run 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, conducted February 23, 2022, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room as there was no coverings over the door in the dining room that also serves as a group room.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On the day of the physical plant inspection, facility maintenance sprayed frost over the window of the door in the dining room to ensure privacy so that counseling sessions cannot be seen outside the counseling room.
Facility maintenance staff will conduct environmental rounds on a weekly basis to ensure counseling rooms are kept private through door/window coverings and sound machines.
Facility maintenance staff will submit environmental rounds to the Facility Director on a weekly basis to monitor for compliance. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drills from January 2021 through January 2022 the facility failed to conduct a sleeping fire drill at least every six months. The last sleeping fire drill was completed on March 17, 2021.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The facility Safety Officer will create and follow a grid listing fire drill dates and shifts for the entire year. The grid will serve as a tracking system to ensure a sleeping fire drill is completed at least every six months. The grid will be reviewed with facility Risk Manager on a monthly basis to monitor for compliance. |
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.
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Observations
Based on the review of thirteen client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one client record reviewed.
Client #6 was admitted on November 6, 2021 and was discharged on November 11, 2021. There was documentation that a report was made to the local police department on November 9, 2021; however, there was no proper consent to release information form signed by the client prior to disclosure.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The facility Risk Manager will conduct Confidentiality training with instruction on how to complete a consent with all staff responsible for completing consents at the facility, namely nursing, clinical, intake/admissions and case management. A sign in sheet will be completed an maintained for record.
Additionally, all staff responsible for completing consents will be required to take DDAP Confidentiality training on PA Train. Training certificates will be maintained in employee training files.
Quality Director will conduct confidentiality training during all new employee orientation trainings, which will include training on how to complete a consent. New employee orientation will occur on a monthly basis, as needed.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
Client #6 is no longer in treatment at the facility and a consent is unable to be maintained. |
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 a review of thirteen client records, the facility failed to ensure that all consent to release forms contained the specific information to be released in four client records reviewed.
Client #1 was admitted on February 21, 2022 and was still active at the time of inspection. A consent to release form was signed and dated on February 21, 2022, to a county agency and emergency contact that failed to document specific information to be released.
Client #3 was admitted on February 21, 2022 and was still active at the time of the inspection. A consent to release form was signed and dated on February 21, 2022 to the emergency contact failed to document specific information to be released.
Client #5 was admitted on January 4, 2022 and was discharged on January 9, 2022. A consent to release form was signed and dated on January 4, 2022, to the emergency contact failed to document specific information released.
Client #9 was admitted on December 14, 2021 and was still active at the time of the inspection. A consent to release form was signed and dated on December 14, 2021, to the emergency contact failed to document specific information released.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The facility Risk Manager will conduct Confidentiality training with instruction on how to complete a consent with all staff responsible for completing consents at the facility, namely nursing, clinical, intake/admissions and case management. A sign in sheet will be completed an maintained for record.
Additionally, all staff responsible for completing consents will be required to take DDAP Confidentiality training on PA Train. Training certificates will be maintained in employee training files.
Quality Director will conduct confidentiality training during all new employee orientation trainings, which will include training on how to complete a consent. New employee orientation will occur on a monthly basis, as needed.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
Clients #1, 3, 5 and 9 consents are unable to be obtained due to clients no longer being in treatment. |
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 a review of thirteen client records, the facility failed to ensure that one consent to release information contained a purpose of disclosure.
Client #2 was admitted on February 18, 2022 and was still active at the time of the inspection. A consent to release form was signed and dated on February 18, 2022, to a hospital that failed to include the purpose of disclosure.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The facility Risk Manager will conduct Confidentiality training with instruction on how to complete a consent with all staff responsible for completing consents at the facility, namely nursing, clinical, intake/admissions and case management. A sign in sheet will be completed an maintained for record.
Additionally, all staff responsible for completing consents will be required to take DDAP Confidentiality training on PA Train. Training certificates will be maintained in employee training files.
Quality Director will conduct confidentiality training during all new employee orientation trainings, which will include training on how to complete a consent. New employee orientation will occur on a monthly basis, as needed.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
Client #2 consent is unable to be maintained due to client no longer being at the facility. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of thirteen client records, the facility failed to ensure that a consent to release form contained a dated signature of witness in one client record reviewed.
Client #2 was admitted on February 18, 2021 and was still active at the time of inspection. A consent to release form was signed and dated on February 21, 2021, to an outside agency that failed to include a dated signature of witness.
These findings were discussed with Facility staff during the inspection process.
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Plan of Correction
The facility Risk Manager will conduct Confidentiality training with instruction on how to complete a consent with all staff responsible for completing consents at the facility, namely nursing, clinical, intake/admissions and case management. A sign in sheet will be completed an maintained for record.
Additionally, all staff responsible for completing consents will be required to take DDAP Confidentiality training on PA Train. Training certificates will be maintained in employee training files.
Quality Director will conduct confidentiality training during all new employee orientation trainings, which will include training on how to complete a consent. New employee orientation will occur on a monthly basis, as needed.
Random, monthly chart audits will be conducted by a quality committee with at least one member from each unit to monitor for compliance. Results of the audit will be submitted to the Quality Director on a monthly basis.
Client #2 consent is unable to be obtained due to client no longer being at the facility. |
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 thirteen client records, the facility failed to provide a complete client record, which is to include a discharge summary in three applicable client records reviewed.
Client #11 was admitted on November 24, 2021 and was discharged on December 20, 2021. The client record did not contain documentation that a discharge summary was completed.
Client #12 was admitted on October 23, 2021 and was discharged on November 24, 2021. The client record did not contain documentation that a discharge summary was completed.
Client #13 was admitted on December 19, 2021 and was discharged on December 30, 2021. The client record did not contain documentation that a discharge summary was completed.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Nursing and Clinical staff will be re-trained by the Clinical Supervisor on timeliness and completion of a Multi-Disciplinary Discharge summaries. This training will occur no later than 4/1/22. A sign in sheet will be obtained and kept on record.
Random monthly chart audits will be conducted by the Chart to Charge committee to monitor for compliance. Clinical Supervisor and Nurse Manager will conduct monthly chart audits to monitor for compliance. Results of chart audits will be submitted to the Quality Director on a monthly basis. |