INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 11-12, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on a review of the project ' s policy and procedure manual on March 6, 2020, the project failed to ensure that the staff persons meet the educational qualification requirements of chapter 704.
During the April 23, 2019 inspection, facility staff stated that their Counselor 2 position was the equivalent of a counselor as per the Department of Drug and Alcohol Programs staffing requirements. However, the position description for a Counselor 2 only requires a high school diploma, and not an Associate degree or higher.
The findings were reviewed with facility staff during the licensing process. This is a repeat citation from the April 23, 2019 annual licensing inspection.
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Plan of Correction
The facility QI/Risk Manager worked with the White Deer Run leadership team and corrected the typo on the job description for the Counselor 2 position from the word "now" to "not". The sentence now reads: The Department of Drug and Alcohol Program Licensure in Pennsylvania does not allow for a Counselor II level clinician to have a high school diploma only. The job description has been updated throughout the region. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of Fire Drill from February 2019 until February 2020 the facility failed to ensure that fire drills were done at varying times of the month as ten of the twelve drills were completed on the last day of the month or last Friday of the month.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility safety officer will create a schedule of unannounced fire drills, which will vary in date, time and shift to ensure fire drills are conducted on different days of the week, at different times of the day and night and on different staffing shifts. The facility safety officer will send fire drill forms to the Regional QI/Risk Manager on a monthly basis who will monitor for compliance. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of fourteen client records, the facility failed to document a completed consent to release information in 2 records, as there were forms that were missing required information.
Client #1 was admitted on March 4, 2020 and was still active at the time of the inspection. There was a consent to release form, signed and dated on March 4, 2020, that failed to include a name of a person, agnecy or organization to whom the disclosure is made.
Client #14 was admitted on September 6, 2019 and was discharged on October 4, 2019. There was a consent to release form, signed and dated on October 2, 2019, that failed to include a name of a person, agnecy or organization to whom the disclosure is made.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Nurse Manager will complete a consent training with the nursing staff and will review the requirements for consents to be completed in their entirety and to ensure blank consents are not being signed. A sign in sheet will be maintained by the Nurse Manager to indicate attendance at the training. The nurse manager will conduct random, monthly chart audits to monitor for compliance. |
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 fourteen client records, the facility failed to document a completed consent to release information in four records, as there were forms that were missing required information.
Client #1 was admitted on March 4, 2020 and was still active at the time of the inspection. There was a consent to release form, signed and dated on March 4, 2020, that was missing specific information disclosed.
Client #12 was admitted on August 16, 2019 and was discharged on September 3, 2019. There was a consent to release form, signed and dated on September 1, 2019 to an external provider, that was misisng specific information disclosed
Client #13 was admitted on August 23, 2019 and was discharged on September 21, 2019. There was a consent to release form, signed and dated on August 24,2019 to an county office that was misisng specific information disclosed.
Client #14 was admitted on September 6, 2019 and was discharged on October 4, 2019. There was a consent to release form, signed and dated on September 6, 2019 to a county office that was misisng specific information disclosed
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Nurse Manager will complete a consent training with the nursing staff and will review the requirements for consents to be completed in their entirety and to ensure blank consents are not being signed. A sign in sheet will be maintained by the Nurse Manager to indicate attendance at the training. The nurse manager will conduct random, monthly chart audits to monitor for compliance.
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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 fourteen client records, the facility failed to document a completed consent to release information in two records, as there were forms that were missing required information.
Client #12 was admitted on August 16, 2019 and was discharged on September 3, 2019. There was a consent to release form, signed and dated on September 1, 2019 to an external provider, that was misisng purpose of disclsure
Client #14 was admitted on September 6, 2019 and was discharged on October 4, 2019. There was a consent to release form, signed and dated on September 6, 2019 to a county office that was misisng specific purpose of dicslosure.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Nurse Manager will complete a consent training with the nursing staff and will review the requirements for consents to be completed in their entirety and to ensure blank consents are not being signed. A sign in sheet will be maintained by the Nurse Manager to indicate attendance at the training. The nurse manager will conduct random, monthly chart audits to monitor for compliance.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a phsyical plant inspection of the medication room and discussion with medical staff, the medical staff were unaware of where to find and locate copies of drug-related regulation.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility Nurse Manager will place drug related regulations in the medication room. The facility Nurse Manager will review the regulations at the next scheduled nursing meeting on April 30, 2020. A sign in sheet will be maintained by the nurse manager as documentation of review. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of policy and procedure the project failed to develop and implement policies and procedures to respond to the incident of Physical assault or sexual assault by staff or a client.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility QI/Risk Manager worked with the White Deer Run leadership team and revised the policy for Unusual Incident reporting so that it lists a specific response to each incident. The policy has been updated throughout the region. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of policy and procedure the project failed to develop and implement policies and procedures to respond to the incident of Selling or use of illicit drugs on the premises.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility QI/Risk Manager worked with the White Deer Run leadership team and revised the policy for Unusual Incident reporting so that it lists a specific response to each incident. The policy has been updated throughout the region. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of policy and procedure the project failed to develop and implement policies and procedures to respond to the incident of Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility QI/Risk Manager worked with the White Deer Run leadership team and revised the policy for Unusual Incident reporting so that it lists a specific response to each incident. The policy has been updated throughout the region. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of policy and procedure the project failed to develop and implement policies and procedures to respond to the incident of Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility QI/Risk Manager worked with the White Deer Run leadership team and revised the policy for Unusual Incident reporting so that it lists a specific response to each incident. The policy has been updated throughout the region. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of policy and procedure the project failed to develop and implement policies and procedures to respond to the incident of Theft, burglary, break-in or similar incident at the facility.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility QI/Risk Manager worked with the White Deer Run leadership team and revised the policy for Unusual Incident reporting so that it lists a specific response to each incident. The policy has been updated throughout the region. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of policy and procedure the project failed to develop and implement policies and procedures to respond to the incident of Event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility QI/Risk Manager worked with the White Deer Run leadership team and revised the policy for Unusual Incident reporting so that it lists a specific response to each incident. The policy has been updated throughout the region. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of policy and procedure the project failed to develop and implement policies and procedures to respond to the incident of Fire or structural damage to the facility.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility QI/Risk Manager worked with the White Deer Run leadership team and revised the policy for Unusual Incident reporting so that it lists a specific response to each incident. The policy has been updated throughout the region. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of policy and procedure the project failed to develop and implement policies and procedures to respond to the incident of Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility QI/Risk Manager worked with the White Deer Run leadership team and revised the policy for Unusual Incident reporting so that it lists a specific response to each incident. The policy has been updated throughout the region. |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
Based on a review of policy and procedure the project failed to develop and implement policies and procedures to Documentation of the unusual incident.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility QI/Risk Manager worked with the White Deer Run leadership team and revised the policy on unusual incident reporting to indicate that Nursing staff will document an unusual incident on the Unusual Incident Report Form and will be submitted utilizing the Department of Drug and Alcohol Programs Electronic Reporting System (ERS). |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
Based on a review of policy and procedure the project failed to develop and implement policies and procedures to Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility QI/Risk Manager worked with the White Deer Run leadership team and revised the policy on unusual incident reporting to indicate that Nursing staff will document an unusual incident on the Unusual Incident Report Form and will be submitted utilizing the Department of Drug and Alcohol Programs Electronic Reporting System (ERS).
In addition to reporting the unusual incident, the facility Risk Manager will investigate any unusual incidents that occurs within the facility to determine causes directly or indirectly responsible for the unusual incident. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on a review of policy and procedure the project failed to develop and implement policies and procedures to Implementation of a timely and appropriate corrective action plan, when indicated.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility QI/Risk Manager worked with the White Deer Run leadership team and revised the policy on unusual incident reporting. The facility Risk Manager will investigate any unusual incidents that occurs within the facility. The Risk Manager, Clinical Supervisor and/or Nurse Manager will ensure a timely and appropriate corrective action plan will be implemented to prevent reoccurrence. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of policy and procedure the project failed to develop and implement policies and procedures to Ongoing monitoring of the corrective action plan.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility QI/Risk Manager worked with the White Deer Run leadership team and revised the policy on unusual incident reporting. The facility Risk Manager will investigate any unusual incidents that occurs within the facility. The Risk Manager, Clinical Supervisor and/or Nurse Manager will ensure a timely and appropriate corrective action plan will be implemented to prevent reoccurrence. The Risk Manager, Clinical Supervisor and/or Nurse Manager will monitor the corrective action plan to ensure compliance. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
Based on a review of policy and procedure the project failed to develop and implement policies and procedures to Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility QI/Risk Manager worked with the White Deer Run leadership team and revised the policy on unusual incident reporting to indicate that Nursing staff will document an unusual incident on the Unusual Incident Report Form and will be submitted utilizing the Department of Drug and Alcohol Programs Electronic Reporting System (ERS). Nurse Manager reviews all unusual incident reports prior to submission and ensures it is compliant with State and Federal confidentiality laws. |