INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on February 5, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document that two out of five counselors met both the education and experiential qualifications for the position.
Employee #6, who was hired as a counselor on July 31, 2023, did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience required to be a counselor with a bachelor's degree.
Employee #7, who was hired as a counselor on September 5, 2023, did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience required to be a counselor with a bachelor's degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will follow counselor requirements from DDAP for hiring and supervision.
The facility will be sending a letter to request Act 66 flexibility in the hiring requirement.
The Clinical Director will review employee resumes prior to hiring to determine if they meet the requirements for a Counselor and proceed with the correct form of supervision.
Ongoing: Human Resources and the Campus Director will determine if a candidate is to be hired and the requirements they will need. |
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 the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for one out of two applicable counselors.
Employee #5 was hired as a counselor on December 19, 2019 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2023 through December 31, 2023. Employee # 5's record only document 21 hours of annual training for the training year reviewed.
This is a repeat citation from the January 10, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that all counselors will complete at least 25 hours of training annually in the designated areas.
Over the next 90 days, the Clinical Director will meet with all counselors to ensure that they are completing training hours towards their required annual 25 hour minimum.
Ongoing: The Clinical Director will meet with each counselor on a quarterly basis to ensure that they are progressing towards their annual 25 hour training requirement. |
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 a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in two out of eleven records reviewed.
Client #1 was admitted on February 3, 2024 and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information to a medical provider signed by the client on February 4, 2024, that had identified the purpose for disclosure as other, however no information was listed for what the other purpose was.
Client #3 was admitted on January 30, 2024 and was still active at the time of the inspection. The record contained an informed and voluntary consent to release information to an emergency contact signed by the client on February 4, 2024, that had identified the purpose for disclosure as other, however no information was listed for what the other purpose was.
This is a repeat citation from February 23, 2022 and February 10, 2023 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will obtain an informed and voluntary consent from the client for the disclosure of information in the client record.
Quality/Risk Manager will conduct a training on consents at the facility by March 29, 2024 where employees will be trained on the correct procedures to obtain a consent. The Clinical Director and Nurse Manager will pull five random charts weekly over the next 60 days to review and document that consents are being completed correctly.
As the clients reviewed in this audit are now discharged, no further action can be completed with their consents.
Ongoing: Monthly chart audits will be completed by the Clinical Director to ensure that consents are being completed correctly. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of administrative information, and personnel records submitted, the facility failed to develop a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
The following materials were requested however the facility was unable to provide them during the licensing process:
A completed Staffing Requirement Facility Summary Report (SRFSR), qualifications for clinical staff, individual training plan information, individual work performances evaluations, and the information related to clinical staff and the hours dedicated to detox patients.
This finding was reviewed with the facility during the licensing process.
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Plan of Correction
The facility will complete pre-submission documentation including staffing summary report, training plans, work performances and data collection prior to the inspection.
Quality/Risk Manager has received technical support training on 2/28/2024 on the pre-submission process.
Quality/Risk Manager along with Human Resources will provide training to all leadership on proper completion of staffing grids as well as submission of documentation by 3/29/2024.
Ongoing: Quality/Risk Manager and Human Resources will ensure staffing grids and required documentation is submitted for inspections. |
709.63(a)(6) LICENSURE Aftercare plan
709.63. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include an aftercare plan in one out of one applicable record reviewed. Per the facility ' s policy and procedure manual, the aftercare plan is developed with the client prior to discharged and signed by the client.
Client #5 was admitted on November 10, 2023 and discharged on November 15, 2023. There was no documentation that an aftercare plan was developed with the client.
This is a repeat citation from the February 10, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility shall maintain a complete client record for each client which shall include aftercare plans and will be developed with the client prior to discharge and signed by the client.
For the next 60 days, the Clinical Director will audit five charts per week to confirm that they contain aftercare plans which were developed prior to discharge and signed by the client.
Ongoing; The Clinical Director will conduct quarterly audits to ensure that aftercare plans were developed prior to discharge and were signed by the client. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in one out of one applicable record reviewed. Per the facility ' s policy and procedure manual the discharge summary is to be completed within seven days of discharge.
Client #5 was admitted on November 10, 2023 and discharged on November 15, 2023. There was no documentation that a discharge summary was completed.
This is a repeat citation from the February 10, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility shall maitain a complete client record for each client which shall include a discharge summary which has been completed within seven days of discharge.
For the next 60 days, the Clinical Director will audit five charts per week to confirm that they include a discharge summary which has been completed within seven days of discharge.
Ongoing: The Clinical Director will conduct quarterly chart audits to ensure that discharge summaries were completed within seven days of discharge. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow up information in one out of one applicable record reviewed.
Client #5 was admitted on November 10, 2023 and discharged on November 15, 2023. There was no documentation of follow up information in the client record.
This is a repeat citation from the February 10, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility shall maintain a complete client record which includes follow-up contact within 7 days if an aftercare appointment was made and within 30 days if no appointment was scheduled.
For the next 60 days, the Clinical Director will audit five charts per week to ensure that they include documentation of a follow-up contact being made within 7 days if an aftercare appointment was made or within 30 days if no appointment was scheduled.
Ongoing: The Clinical Director will conduct quarterly chart audits to ensure follow-up contacts were made within 7 days if an aftercare appointment was made or within 30 days if no appointment was scheduled.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to provide a treatment and rehabilitation plan that included the type and frequency of services in five out of seven records reviewed.
Client #4 was admitted on February 3, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on February 4, 2024 that did not include the type and frequency of services.
Client #6 was admitted on October 12, 2023 a discharged on November 6, 2023. A comprehensive treatment plan was developed on October 12, 2023, that did not include the type and frequency of services.
Client #7 was admitted on September 10, 2023 and discharged on October 10, 2023. A comprehensive treatment plan was developed on September 11, 2023, that did not include type and frequency of services.
Client #9 was admitted on October 12, 2023 and discharged on October 24, 2023. A comprehensive treatment plan was developed on October 20, 2023, that did not include type and frequency of services.
Client# 11 was admitted on December 13, 2023 and still active at the time of the inspection. A comprehensive treatment plan was developed on December 22, 2023, that did not include type and frequency of services.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Individualized Treatment Plan that is developed with the client will include type and frequency of treatment services.
The Clinical Director has met with the clinical team and provided education on this requirement.
Clients who were identified during the inspection have all been discharged from the program. The program is unable to meet with them to amend their Individualized Treatment Plans.
The Clinical Director will pull five charts per week for the next 60 days to perform chart audits to confirm all charts include type and frequency of treatment services.
Ongoing: The Clinical Director will conduct quarterly chart audits to ensure that Individualized Treatment Plans contain type and frequency of treatment services. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include an aftercare plan in two out of three applicable records reviewed. Per the facility ' s policy and procedure manual, the aftercare plan is developed with the client prior to discharged and signed by the client.
Client #7 was admitted on September 10, 2023 and discharged on October 10, 2023. There was no documentation that an aftercare plan was developed with the client.
Client #8 was admitted on July 18, 2023 and discharged on September 8, 2023. The aftercare plan was due prior to September 8, 2023; however, it was not completed until September 11, 2023 and was not signed by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility shall maintain a complete client record for each client which shall include aftercare plans which will be developed with the client prior to discharge and signed by the client.
For the next 60 days, the Clinical Director will audit five charts per week to confirm that they contain aftercare plans which were developed prior to discharge and signed by the client.
Ongoing: The Clinical Director will conduct quarterly chart audits to ensure aftercare plans were developed prior to discharge and signed by the client. |
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 client records, the facility failed to provide a complete client record, which is to include a discharge summary in two out of four applicable records reviewed. Per the facility ' s policy and procedure manual the discharge summary is to be completed within seven days of discharge.
Client #7 was admitted on September 10, 2023 and discharged on October 10, 2023. There was no documentation that a discharge summary was completed.
Client #8 was admitted on July 18, 2023 and discharged on September 8, 2023. A discharge summary was due no later than September 15, 2023; however, it was not completed until September 28, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility shall maintain a complete client record for each client which shall include a discharge summary which has been completed within seven days of discharge.
For the next 60 days, the Clinical Director will audit five charts per week to confirm they include a discharge summary which has been completed within seven days of discharge.
Ongoing: The Clinical Director will conduct quarterly chart audits to ensure discharge summaries were completed within seven days of discharge. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a follow up contact in four out of four applicable records reviewed. Per the facility ' s policy and procedure manual, follow up contacts are within 7 days if an aftercare appointment was made or within 30 days if no appointment was scheduled.
Client #6 was admitted on October 12, 2023 and discharged on November 6, 2023. There is no documentation that a follow up occurred.
Client #7 was admitted on September 10, 2023 and discharged on October 10, 2023. There is no documentation that a follow up occurred.
Client #8 was admitted on July 18, 2023 an discharged on September 8, 2023. There is no documentation that a follow up occurred.
Client#9 was admitted on October 12, 2023 and discharged on October 24, 2023. There is no documentation that a follow up occurred.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility shall maintain a complete client record which includes a follow-up contact within 7 days if an aftercare appoointment was made or within 30 days if no appointment was scheduled.
For the next 60 days, the Clinical Director will audit five charts per week to ensure that they include documentation of a follow-up contact within 7 days if an aftercare appointment was made or 30 days if no appointment was scheduled.
Ongoing: The Clinical Director will conduct quarterly chart audits to ensure that follow-up contacts were made within 7 days if an aftercare appointment was made or within 30 days if no appointment was scheduled. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for ensuring that the project obtained an informed and voluntary consent from the client for the disclosure of information contained in the client record that includes the purpose of the disclosure was submitted and approved by the Department for the February 23, 2022, and February 10, 2023, annual licensing inspections. Completing and documenting an informed and voluntary consent to release information containing the purpose was again found to be a deficiency in the February 5, 2024, licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with plans of correction that were approved by the Department.
Over the next 90 days the Campus Director will review the Plan of Correction to ensure compliance.
Ongoing: The Campus Director will conduct quarterly reviews of the Plan of Correction to ensure compliance. |