INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 1-3rd 2019 of White Deer Run, Inc 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, White Deer Run, Inc 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:
|
Plan of Correction
|
704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
|
Observations
Based on a review of the project's policy and procedure manual, position descriptions, and an interview with facility staff, the project failed to ensure that the staff persons meet the educational and experiential qualification requirements of chapter 704. The position description for the Director of Program Management, also known as the Facility Director, does not include the requirement that the person have experience in program planning. The facility staff stated that their Counselor 2 position, was the equivalent of a counselor as per the Department of Drug and Alcohol Programs staffing regulations. 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.
|
Plan of Correction
The HR department ensure the need for experience in program planning as a qualification for the Facility Director role will be added to the system's job description.
The line stating that a high school diploma is acceptable for a Counselor level position will be removed from the Counselor 2 job description by the HR manager. A line stating the education requirement for a counselor is a minimum of an associate's degree in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in human services) or other related field will be added by the HR manager.
The executive director's designee will review the project's policies and procedures against DDAP regulations annually to ensure compliance.
|
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.
|
Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #24 and #25 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee #24 was hired as a Intake Coordinator on March 6, 2017 and was due to have the communicable disease trainings no later than March 6, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.Employee #2 was hired as a Unit Cleark on March 6, 2017 and was due to have the communicable disease trainings no later than March 6, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Infection Control Nurse will track employee's communicable disease training and alert staff on a quarterly basis who is still in need of trainings prior to the quarterly trainings being offered to ensure staff attendance and compliance with regulation.
Infection control nurse will send alert to employee/supervisor a month prior to last offered on-site communicable disease training before employee would be out of compliance. If employee fails to register for this training an alert will go to the supervisor and the supervisors direct report alerting that the employee will be out of compliance 1 week prior to training. If employee/supervisor fails to register employee for training an alert will go to CEO 2 days prior to training informing of concern w/ noncompliance w/ regulatory standard.
Failure to attend training within required timeframe will result in disciplinary action.
|
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
|
Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy or procedure for utilization of volunteers.These findings were reviewed with facility during the licensing inspection.
|
Plan of Correction
The executive director will create a policy in relation to volunteers for the system.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
|
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
|
Observations
Based on a review of the project's policy and procedure manual, the project's confidentiality policy does not include 4 Pa. 255.5(a)(6) identifying the limitation of information that may be disclosed to employers or prospective employers of the client. In addition, project's policy and procedure manual does not identify the person responsible for maintaining electronic records. These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The executive director will revise the confidentiality policy so it includes the limitation of information that may be disclosed to employers of the client.
The executive director will revise the confidentiality policy to include identification of the person responsible for maintaining electronic records.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
|
709.28 (a) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
|
Observations
Based on a review of the project's policy and procedure manual, the project's procedures do not address the methods by which staff gain access to electronic records.These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The executive director will revise the confidentiality policy so it addresses the methods by which staff gain access to medical records.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing 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.
|
Observations
Based on a review of fourteen client records, the facility failed to keep disclosures of client identifying information within the limited established by 4 Pa. Code 255.5 (b) for releases of information in eight client records reviewed. Client #1 was admitted on April 28, 2019 and was still active at the time of the inspection. A consent to release information was signed and dated on April 28, 2019 to a county government agency that allowed for the release of psychiatric evaluation, history & physical, discharge summary, laboratory reports, medication records, treatment/individualized service plan, discharge instruction, case consult, biopsychosocial/diagnostic, nursing assessment and PPD. Client #5 was admitted on July 13, 2018 and discharged on July 17, 2018. Client was readmitted on September 7, 2018 and discharged on September 24, 2018. A consent to release information was signed and dated on July 13, 2018 to a county government agency that allowed for the release of psychiatric evaluation, history & physical, discharge summary, laboratory reports, medication records, treatment/individualized service plan, discharge instruction, case consult, biopsychosocial/diagnostic, nursing assessment and PPD. Client #8 was admitted on april 6, 2019 and was still active at the time of the inspection. A consent to release information was signed and dated on April 6, 2019 to a county government agency that allowed for the release of psychiatric evaluation, history & physical, discharge summary, laboratory reports, medication records, treatment/individualized service plan, discharge instruction, case consult, biopsychosocial/diagnostic, nursing assessment and PPD. Client #9 was admitted on February 21, 2019 and was still active at the time of the inspection. A consent to release information was signed and dated on February 21, 2019 to a county government agency that allowed for the release of psychiatric evaluation, history & physical, discharge summary, laboratory reports, medication records, treatment/individualized service plan, discharge instruction, case consult, biopsychosocial/diagnostic, nursing assessment and PPD. Client #10 was admitted on April 24, 2019 and was still active at the time of the inspection. A consent to release information was signed and dated on April 14, 2019 to a county government agency that allowed for the release of psychiatric evaluation, history & physical, discharge summary, laboratory reports, medication records, treatment/individualized service plan, discharge instruction, case consult, biopsychosocial/diagnostic, nursing assessment and PPD. Client #11 was admitted on August 17, 2018 and was discharged on September 14, 2018. A consent to release information was signed and dated on August 17, 2019 to a county government agency that allowed for the release of psychiatric evaluation, history & physical, discharge summary, laboratory reports, medication records, treatment/individualized service plan, discharge instruction, case consult, biopsychosocial/diagnostic, nursing assessment and PPD. Client #12 was admitted on October 30, 2018 and discharged on November 20, 2018. A consent to release information was signed and dated on October 30, 2018 to a county government agency that allowed for the release of psychiatric evaluation, history & physical, discharge summary, laboratory reports, medication records, treatment/individualized service plan, discharge instruction, case consult, biopsychosocial/diagnostic, nursing assessment and PPD. Client #14 was admitted on July 31, 2018 and discharged on September 1, 2018. A consent to release information was signed and dated on July 31, 2019 to a county government agency that allowed for the release of psychiatric evaluation, history & physical, discharge summary, laboratory reports, medication records, treatment/individualized service plan, discharge instruction, case consult, biopsychosocial/diagnostic, nursing assessment and PPD. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Medical Records Manager facilitated training on 5/16/19 for staff identified having completed invalid consent.
A new electronic medical record (EMR) was implemented which has consents set up by defining the purpose/type of the consent and possible fields permitted for the type of consent chosen.
Effective 6/15/19 a change will occur with EMR that requires staff to make appropriate selections in areas pertaining to information released and purpose of disclosure before a signature will be accepted.
All staff will attend annual training which includes confidentiality, trainers will review confidentiality regulations with staff.
|
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.
|
Observations
Based on a review of fourteen client records, the facility failed to document a completed consent to release information in one record, as there were forms that were missing required information.Client #5 was admitted on November 12, 2018 and discharged on January 30, 2019. Four consent to release forms did not include the purpose of disclosure. The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Medical Records Manager facilitated training on 5/16/19 for staff identified having completed invalid consent.
A new electronic medical record (EMR) was implemented which has consents set up by defining the purpose/type of the consent and possible fields permitted for the type of consent chosen.
Effective 6/15/19 a change will occur with EMR that requires staff to make appropriate selections in areas pertaining to information released and purpose of disclosure before a signature will be accepted.
All staff will attend annual training which includes confidentiality, trainers will review confidentiality regulations with staff.
|
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on a review of the project's policy and procedure manual, the project failed to include in its policies that that the project may not discriminate in the provision of services based on age, ethnicity, marital status and/or creed.The Intake and Admission Continuum of Care Policy and Procedure for Intake and Admissions for Partial Hospital, Outpatient Part II and Adult Admission Criteria Part II, does not include age, ethnicity, and marital status for those who will not be discriminated against. The Intake and Admission Continuum of Care Policy and Procedure for Intake and Admissions for the Intake, Evaluation and Referral Activity does not include age, ethnicity, and marital status for those who will not be discriminated against. In the project's Rights Responsibilities and Ethics (RI), subject "Patients Rights" Policy and Procedure, Under Procedure: A. 1. "creed" is not included.The signed client rights documentation in the client's record does not include creed for those who will not be discriminated against.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The executive director will revise the patient rights so they include that the project may not discriminate in the provision of services based on age, ethnicity, marital status and/or creed.
The executive director will add "creed" to the Rights Responsibilities and Ethics subject "Patient Rights" policy and procedure A.1. section.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
|
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
|
Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy or procedure for documentation of medication administration when self-administered by the client.These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The executive director will revise the current policy that exists on medication administration and self-administration so it includes reference to the current self medication documentation form.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
|
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.
|
Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy relating to maintaining copies of drug-related regulations being available in appropriate areas.These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The executive director will add a policy that addresses the need to maintain copies of drug-related regulations in appropriate areas to the regional policy and procedure manual.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
|
715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
|
Observations
Based on a review of the project ' s policy and procedure manual, the project does not have a procedure in place to address the requirements in 715.22(b).The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The executive director will revise the current grievance procedure so it addresses permitting patients to have a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director and to address grievances filed by patients against the narcotic treatment program director.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
|
715.22(c) LICENSURE Patient grievance procedures
(c) Penalties may not be initiated prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to commit acts of physical violence in or around the narcotic treatment program premises.
|
Observations
Based on a review of the project ' s policy and procedure manual, the project does not have a procedure in place to address the requirements in 715.22(c ). The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The executive director will update the grievance procedure to address penalties being initiated against patients prior to the final resolution of grievances.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
|
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
|
Observations
Based on a review of seven detoxification patients, the facility failed to document a psychosocial evaluation in three client records.Client # 1 was admitted on April 28, 2019 and was still active at the time of the inspection.Client #3 was admitted on September 19, 2018 and was discharged on October 10, 2018.Client #4 was admitted on August 5, 2018 and discharged on August 19, 2018. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
CEO and Clinical Director have implemented and trained staff on the use of a clinical work-flow tracking sheet which identifies required documentation and timeframes.
Clinical supervisors will ensure compliance with documentation/timeframes by reviewing the clinical work-flow sheets weekly and conducting random audits of charts and work flow sheets.
Deficient documentation will result in supervision and/or further disciplinary action.
|
715.24(5)(iv) LICENSURE Narcotic detoxification
If a narcotic treatment program provides narcotic detoxification services, the narcotic treatment program shall develop and implement narcotic detoxification policies and procedures which include the following:
(5) Minimum requirements for long-term detoxification treatment are as follows:
(iv) A narcotic treatment program shall observe the patient while ingesting the medication at least 6 days a week.
|
Observations
Based on an observation of eleven medication administrations during the physical plant inspection, the facility failed to ensure four clients ingested the medication following administration. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Distributing nursing staff will inform patients prior to distribution of narcotic detoxification that they will be doing mouth checks before and after distribution of the medications.
Patients will be asked after distribution of medication to drink 3 cups of water, and either talk to staff or do a mouth check before they are permitted to leave.
To ensure compliance with this practice Ast. Director of Nursing will do random observations during distribution of narcotic detoxification at least 1x/week.
|
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in two of two applicable client records reviewed.Client #9 was admitted on February 21, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was completed on February 27, 2019 and the next update was due no later than March 27, 2019 ; however, there was no update documented in the record until April 21, 2019.Client #13 was admitted on January 28, 2019 and was discharged on April 25, 2019. The comprehensive treatment plan was completed on January 30, 2019 and the next update was due no later than March 2nd 2019; however, there was no update documented in the record at the time of inspection.These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
CEO and Clinical Director have implemented and trained staff on the use of a clinical work-flow tracking sheet which identifies required documentation and timeframes.
Clinical supervisors will ensure compliance with documentation/timeframes by reviewing the clinical work-flow sheets weekly and conducting random audits of charts and work flow sheets.
Deficient documentation will result in supervision and/or further disciplinary action.
|
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of seven inpatient client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in five charts reviewed.Client #8 was admitted on April 6, 2019and was still active at the time of the inspection. The comprehensive treatment plan, dated April 13, 2019, indicated five group sessions per week. The chart's record of service and progress notes indicated that the client only recieved two groups on April 18, 2019 and April 27, 2019. Client #9 was admitted on February 21, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated February 27, 2019 , indicated One individual session a week. The chart's record of service and progress notes indicated that the client had received no individual sessions from March 6, 2019- March 28, 2019. Client #10 was admitted on April 14, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated April 26, 2019 , indicated seven group sessions per week. The chart's record of service and progress notes indicated that the client had received no group sessions since April 28th 2019. Client #11 was admitted on August 17, 2018 and was discharged on September 14, 2018. The comprehensive treatment plan, dated August 20, 2018 , indicated five group sessions per week and one individual session per week. The chart's record of service and progress notes indicated that the client had received no group sessions or Individual sessions between August 19th-August 26th 2018. Client #13 was admitted on January 13, 2019 and was discharged on April 25, 2019. The comprehensive treatment plan, dated January 30, 2019, indicated five group sessions per week and one individual session per week. The chart's record of service and progress notes indicated that the client had received no individual sessions in February and no individual session from March 14-April 21, 2019. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
CEO and Clinical Director have implemented and trained staff on the use of a clinical work-flow tracking sheet which identifies required documentation and timeframes.
Clinical supervisors will ensure compliance with documentation/timeframes by reviewing the clinical work-flow sheets weekly and conducting random audits of charts and work flow sheets.
Deficient documentation will result in supervision and/or further disciplinary action.
Clinical director will facilitate a training session for all staff to review regulations and expectations so that staff understand how to ensure that treatment plan, and services indicated on treatment plan is being accurately recorded in the charting.
|
709.53(a) LICENSURE Complete Client Record
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:
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summaries in client records#12, 13, and 14.Client #12 was admitted on October 30, 2018 and was discharged on November 20th, 2018. The client record did not contain documentation of a dischary summary.Client #13 was admitted on January 28, 2019 and was discharged on April 25th, 2019. The client record did not contain documentation of a discharge summary. Client #14 was admitted on July 31, 2018 and was discharged on September 1, 2019. The client record did not contain documentation of a discharge summary. These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
CEO and Clinical Director have implemented and trained staff on the use of a clinical work-flow tracking sheet which identifies required documentation and timeframes.
Clinical supervisors will ensure compliance with documentation/timeframes by reviewing the clinical work-flow sheets weekly and conducting random audits of charts and work flow sheets.
Deficient documentation will result in supervision and/or further disciplinary action.
|