INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 15-16, 2018, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Perspective 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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704.11(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 facility records conducted as part of the presubmission process, and based on staff interviews conducted during the on-site inspection, the facility failed to ensure that all of its staff had the required training in communicable diseases.
Staff Person # 8 was hired as a support staff person on 11/23/2015, and was required to complete 6 hours of HIV/AIDS training, and 4 hours of TB/STD training by 11/23/2017, but at the time of the on-site inspection the staff person had no documented training in HIV/AIDS or TB/STD.
Staff Person # 9 was hired as a support staff person on 07/08/2015, and was required to complete 6 hours of HIV/AIDS training, and 4 hours of TB/STD training by 07/08/2017, but at the time of the on-site inspection the staff person had no documented training in HIV/AIDS or TB/STD.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Employees #8 and #9 will be scheduled for the next available training.
Campus Director will review progress with department managers on a monthly basis to ensure that employees #8 and #9 receive required training and that all staff are receiving training in accordance with licensure requirements and company policy. |
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 the on-site inspection of the physical plant conducted May 16, 2018, the facility failed to ensure that frozen foods were kept at or below 0 degrees Fahrenheit.
The chest freezer had a temperature of 10 degrees Fahrenheit.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Food preparation staff will record the temperature of freezers and refrigerators on a daily basis and alert their supervisor if out of compliance.
Managers will review the daily logs weekly at a minimum and on a spot check basis to ensure compliance. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based on the on-site inspection of the physical plant conducted May 16, 2018, the facility failed to ensure that none of its food was stored on the floor.
There was a sack of flour, a sack of rice and a box filled with bags of corn chips all stored on the floor of the dry storage area.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Food service staff will ensure that no food is stored on the floor.
Managers/Supervisors will visually inspect the food service areas weekly at a minimum to ensure that no food is stored on the floor. |
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 a review of facility records conducted during the on-site inspection, and based on staff interviews conducted during the on-site inspection, the facility failed to obtain informed and voluntary consents before disclosing information in client records.
Client #2 was admitted for treatment on 04/20/2018. The facility disclosed information to the client's employer on 04/25/2018, but the signed informed consent to release information forms for the employer dated 4/20/2018, and 4/24/2018, did not document the information to be disclosed.
Client #3 was admitted for treatment on 02/08/2018. The facility disclosed information to a recovery house on 02/19/2018, but there was no documented signed informed consent to release information form for the recovery house.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Nurses, clinical staff and case managers will ensure that valid, written consent is obtained prior to disclosing client information.
Nurse manager and clinical supervisor will instruct staff on the importance of adhering to confidentiality regulations and guidelines and train all staff in the proper completion of all forms.
Nurse manager will review all open detox charts after admission.
Clinical supervisor with review a sample of each counselor's open and closed charts at monthly supervision meetings to ensure compliance.
The clients cited have been discharged from the facility. |
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.
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Observations
Based on a review of facility records conducted during the on-site inspection, the facility failed to update client treatment plans at least once every 15 days in 2 of 6 client records reviewed. The facility is a short-term inpatient rehabilitation program with a treatment regimen of 28 days, and the facility is required to update treatment plans at least once every 15 days.
Client #3 was admitted for inpatient rehabilitation treatment on 02/08/2018, and was discharged on 03/04/2018. The client's individualized treatment plan was created on 02/09/2018, but there was no documented treatment plan update.
Client #6 was admitted for inpatient rehabilitation treatment on 02/09/2018, and was discharged on 03/06/2018. The client's individualized treatment plan was created on 02/09/2018, but there was no documented treatment plan update until 03/05/2018.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Clinical supervisor will instruct and train clinical staff/counselors regarding the timelines for the completion of the treatment plan update at least once every 15 days.
Clinical supervisor will sample review open charts during each staff's monthly supervision to ensure the minimum required treatment plan update timeline is adhered to. |