INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 29-30, 2013 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:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff.
The findings include:
One personnel record requiring documentation of HIV/AIDS and TB/STD training was reviewed on April 29, 2013. One out of one record, specifically record # 5, did not contain the required documentation. Employee # 5, a technician, was hired on April 26, 2011. Training was due by April 26, 2013. As of the licensing inspection, there was no documentation of TB/STD training for employee #5.
The findings were confirmed with the facility director during the licensing inspection.
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Plan of Correction
Campus Director is working with supervisor to schedule technician to receive STD/TB training. The training will be completed by June 30th, 2013.
QI Coordinator sends out monthly emails that indicates staff training needs. Campus Director and Direct Managers will review this list during monthly management meetings to ensure that all staff are obtaining mandatory trainings within the required time frame. |
709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
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Observations
Based on a review of detox patient records the facility failed to document patient vital signs in physical examinations.
The findings include:
Three detox patient records were reviewed for a physical examination on April 29, 2013. The facility neglected to record the vital signs in the physical examination in three patient records specifically, # 1, 2, and 3.
Client # 1 was admitted on April 22, 2013. The physical examination was completed on April 23, 2013 and did not include documentation of the patient's blood pressure, temperature, weight, or height.
Client # 2 was admitted on April 25, 2013. The physical examination was completed on April 24, 2013 and did not include documentation of the patient's blood pressure, temperature, weight, or height.
Client # 3 was admitted on January 2, 2013 and discharged on January 8, 2013. The physical examination was completed on January 3, 2013 and did not include documentation of the patient ' s blood pressure, temperature, weight, or height.
The findings were discussed with the facility director prior to the exit interview.
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Plan of Correction
Campus Director and Nursing Supervisor have a meeting scheduled with facility physicians to review required paperwork on 5/29/13.
Nurses meeting is scheduled for 5/22/13 to review the expectation that nurses will flag all areas that the attending physician needs tocomplete and will review the paperwork prior to the physician leaving for the day. |
709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
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Observations
Based on the review of inpatient client records, the facility failed to document episodes when a client failed to take a prescribed medication in two of five records.
The findings include:
Five inpatient records were reviewed on April 29, 2013 for documentation of medication administration records. The facility failed to document that a patient did not receive medication as prescribed in two of five client records, specifically records # 6 and 8.
Client # 6 was admitted into inpatient treatment on February 21, 2013 and discharged on March 21, 2013. The client had physician orders to take 21 mg Nicotine patch daily. The client did not receive the medication as prescribed on March 19 and 20, 2013. The facility failed to document why the patient failed to take the medication as prescribed.
Client # 8 was admitted into inpatient treatment on January 13, 2013 and discharged on February 11, 2013. The client had physician orders to take 100 mg of Trazodone nightly. The client did not receive the medication as prescribed on January 21 and 22, 2013. The facility failed to document why the patient failed to take the medication as prescribed.
The findings were discussed with the facility director during the exit interview.
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Plan of Correction
Campus Director and Nursing Supervisor will review completion of MAR's at the nurses' meeting scheduled on May 22nd, 2013.
Nursing Supervisor has created an open chart audit form and will be conducting audits on a weekly basis and will audit 3 open charts each week for the next 6 weeks (until June 30th, 2013) to ensure that documentation is being completed. The open chart audit will include reviewing MARs. |
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 inpatient client records, the facility failed to document discharge summaries according to facility policy.
The findings include:
Facility policy states that discharge summaries will be completed within seven days of discharge.
Three inpatient records were reviewed for documentation of a discharge summary on April 29, 2013. The facility failed to document discharge summaries within seven days of the client being discharged in one of three inpatient client records reviewed, specifically record # 7.
Client # 7 was admitted into inpatient treatment on January 14, 2013 and was discharged on January 23, 2013. As of the date of inspection, the facility did not document a discharge summary for this client #7.
The findings were reviewed with the facility director prior to the exit interview.
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Plan of Correction
Clinical Supervisor will provide onsite training on discharge summaries, to include policy review on May 24th, 2013.
Clinical Supervisor will audit 10 percent of records for each clinician for 3 months, effective immediately to monitor compliance and provide supervision as needed. |