INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 26 through 27, 2009 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on April 25, 2009.
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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 the review of employee records, the facility failed to ensure that all staff received mandatory HIV/AIDS training within the one year timeframe in one of six employee records.
The findings include:
Seven employee records were reviewed on March 26, 2009. HIV/AIDS training was due in six of seven employee records. The facility failed to ensure that employee # 5 received the mandatory HIV/AIDS training within the applicable timeframe.
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Plan of Correction
704.11(c)(1) Mandatory Communicable Disease Training
704.11 Staff development program
Employee #5 received the mandatory 6 hours of HIV/AIDS training on March 30 following the licensing visit. Efforts are in place for supervisors to be electronically notified when a staff member is in need of a state required training so that the facility remains in compliance. The Campus Director will be responsible for maintaining ongoing compliance.
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709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to thoroughly document psychosocial evaluations in three of three detoxification only records.
The findings include:
Four client records were reviewed on March 26 through 27, 2009. Psychosocial evaluations were required in three of client records. The facility did not document complete psychosocial evaluations in client records in records # 1 and 2. Record # 1 was missing composite picture, client problems/needs, assets/strengths, support systems, coping mechanisms and counselor conclusions/impressions; record # 2 was missing composite picture, client problem/needs, support systems, coping mechanisms, negative factors and counselor conclusions/impressions; and # 6 was missing composite picture, client problems/needs, assets/strengths, support systems, coping mechanisms and counselor conclusions/impressions.
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Plan of Correction
709.62(c)(6) Psychosocial Evaluation
709.62 Intake and admission
While the Psychosocial Evaluation was completed on all clients, there is a concern that the information contained in the Evaluation does not contain sufficient detail. The facility Campus Director, Lead Counselor, and Lead Nurse, will develop and conduct a training and an on-going review process for the Clinical and Nursing staff to ensure the level of quality and content of the client file meets regulatory requirements. A refresher training program will be developed by 5/1/2009 and conducted prior to 5/15/2009. Re-training will consist of how to properly and completely document: composite picture of the client; assets and strengths; support systems; coping mechanisms; negative factors; client attitude toward treatment; and counselor conclusions/impressions. The Lead Counselor and Lead Nurse will also conduct on-going reviews of client clinical files and address any quality concerns through the clinical supervision process. The Campus Director will be responsible for maintaining ongoing compliance.
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