INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 16, 2021 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 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of one applicable clinical supervisor ' s qualifications, the facility failed to document a core curriculum in clinical supervision.
Employee #3 was hired as a clinical supervisor in November 2020 and is still current in that position. Employee #3 did not function for 2 years as a supervisor in the provision of clinical services previous to this position; therefore, a core curriculum in clinical supervision is required.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The employee is currently completing the online Clinical Supervision training approved by the Department, which is the first available training she could attend since the COVID 19 Pandemic. The employee will complete the training. Facility Director will monitor to ensure employee completes the training. Certificate of completion will be maintained in the employee's record.
Quality Director will monitor employee trainings on a quarterly basis for compliance with regulations.
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of six personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #6 was hired on May 2, 2021 as a counselor assistant. Employee # 6 has a bachelor ' s degree and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for the first 6 months of employment. Employee #6 did not receive close supervision from May 2, 2021 to present. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " .
Clinical supervision notes for May 27, 2021 and June 3, 2021 discussed direct observation but did not include a formal documented case review. Clinical Supervision notes for June10, 2021 to July 8, 2021 discussed formal case review but did not document direct observation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director and/or Clinical Supervisor will ensure counselor assistants receive close supervision of a trained counselor or clinical supervisor once per week for the first six months of employment.
Employee #6 will receive close supervision until November 2, 2021, which will conclude six months of employment in his position. The close supervision will be completed by a trained counselor or clinical supervisor. Documentation of close supervision will be maintained in the employee's file. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of six personnel records, one applicable record for the facility director failed to document 12 hours of annual training.
Employee #2 was hired as the facility director on February 3, 2019 and is still current in that position. Only 4 hours and 49 minutes of training were documented in the personnel record for the 2020 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will seek and attend trainings to meet her required 12 hours of annual training. In the event trainings begin to be cancelled or not held due to the COVID pandemic, the Facility Director will seek out virtual or web based trainings to meet her required 12 hours of annual training by the end of the training year on 12/31/21. All training certificates will be maintained in the employee's record.
Quality Director will monitor employee trainings on a quarterly basis for compliance with regulations. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of six personnel records, one counselor record failed to document 25 hours of annual training.
Employee #5 was hired as a counselor on November 11, 2019 and is still current in that position. Only 11 hours and 55 minutes of training were documented in the personnel record for the 2020 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will seek and attend trainings to meet the required 25 hours of annual training. In the event trainings begin to be cancelled or not held due to the COVID pandemic, counselors will seek out virtual or web based trainings to meet their required 25 hours of annual training by the end of the training year on 12/31/21. Training certificates will be maintained in the employees' records.
Quality Director will monitor employee trainings on a quarterly basis for compliance with regulations. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection on July 16, 2021, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
At the bottom of the stairs leading to the counselor offices in the basement there was water seeping up from under the tile creating a slippery surface.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The wet area at the bottom of the stairs leading to the counselor offices has been cleaned up and the leak repaired. Facility Safety Officer will continue to monitor facility grounds through monthly Safety Assessment Walk Throughs. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on July 16, 2021, the facility failed to ensure the hot water temperature did not exceed 120F.
The water temperature in the bathroom located in the bedroom marked MB read at 138F.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On July 16, 2021 the temperature to the new hot water heater was turned down so it would not exceed 120F.
The Facility Safety Officer will monitor water temps on a monthly basis while conducting monthly Safety Assessment Walk Throughs. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection on July 16, 2021, the facility failed to clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
The utensils were sitting out in the hallway between the dining area and the kitchen and were not in a clean enclosed area.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective immediately, kitchen staff began covering utensils with plastic and placing them in storage before and after each meal to ensure they are kept in a clean enclosed area.
The Facility Safety Officer will monitor on a monthly basis while conducting monthly Safety Assessment Walk Throughs. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection on July 16, 2021, the facility failed to keep frozen food at or below 0F.
The thermometer in the kitchen freezer read 20F.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Kitchen staff will monitor freezer temps on a daily basis to ensure frozen food is kept at or below 0F. Documentation will be kept in the Temp binder. In the event the freezer has to be opened to place new product inside, it will be completed as quickly as possible to avoid any drop in temperature. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of twelve client records, the facility failed to obtain a dated signature of a client on an informed and voluntary consent for the disclosure of information contained in one client record reviewed.
Client # 10 was admitted on May 25, 2021 and was still a current client. An informed and voluntary consent for the disclosure of information to " Halfway Houses - White Birch, Integrity House, Gate House, Treatment Trends, and Day Star " was signed and dated by a witness on June 2, 2021. The consent did not have a dated signature of the client. Information was disclosed to the halfway houses listed on June 4, 2021.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will re-educat staff during staff meeting in August, 2021 of the importance of obtaining a signed and dated signature of a client on all consents for the disclosure of information.
Client #10 is no longer a client at the facility. Therefore, consent cannot be obtained.
Monthly random chart audits will be completed and monitored for compliance by Quality Director and Facility Director. |
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 review of the medication storage area, the facility was not following their policy for disinfectants and drugs for external use to be stored separately from oral and injectable drugs. In the top drawer of the medication cart client ' s topical ointments were stored alongside client ' s oral medication.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Nurse Manager will re-educate nursing staff during staff meeting in August, 2021 on the requirement for keeping disinfectants and drugs for external use stored separately from oral and injectable drugs.
The client's topical ointment has been moved and stored separately from the client's oral medication.
Random monthly med cart inspections will be completed and Nurse Manager will monitor for compliance. |
709.62(c)(2)(ii) LICENSURE Orientation - Op hours
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of five client records, the facility failed to ensure intake procedures included documentation of the client orientation to the project which includes, but it is not limited to, a familiarization with the hours of operation in all five records reviewed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Intake and Admissions staff will ensure each client receives orientation into the program including the hours of operation. Documentation of orientation will be maintained in the client record.
Random chart audits will be completed on a monthly basis to ensure compliance. |
709.62(c)(2)(iii) LICENSURE Orientation - Fee Schedule
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of five client records, the facility failed to ensure intake procedures included documentation of the client orientation to the project which includes, but it is not limited to, a familiarization with the fee schedule in all five records reviewed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Intake and Admissions staff will ensure each client receives orientation into the program including the fee schedule. Documentation of orientation will be maintained in the client record.
Random monthly chart audits will be completed. Quality Director will monitor for compliance. |
709.51(b)(2)(ii) LICENSURE Hours of Operation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of seven client records, the facility failed to ensure intake procedures included documentation of the client orientation to the project which includes, but it is not limited to, a familiarization with the hours of operation in all seven records reviewed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Intake and Admissions staff will ensure each client receives orientation into the program including the hours of operation. Documentation of orientation will be maintained in the client record.
Random monthly chart audits will be completed. Quality Director will monitor for compliance. |
709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of seven client records, the facility failed to ensure intake procedures included documentation of the client orientation to the project which includes, but it is not limited to, a familiarization with the fee schedule in all seven records reviewed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Intake and Admissions staff will ensure each client receives orientation into the program including the fee schedule. Documentation of orientation will be maintained in the client record.
Random monthly chart audits will be completed. Quality Director will monitor for compliance. |
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 a review of seven client records, the facility failed to ensure a complete client record on an individual included verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan in all seven records reviewed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical staff will work with each client on developing the treatment and rehabilitation plan and add action steps for any work being done by the client at the project. Work will be defined as therapeutic work in each treatment plan.
Random monthly chart audits will be completed. Quality Director will monitor for compliance. |