INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and inspection conducted for the approval to use a narcotic agent, specifically buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on March 24, 2015 through March 25, 2015, by staff from the Department of Drug and Alcohol Programs, Division 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 4 PA Code and 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(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report forms for all facilities within the drug and alcohol treatment project, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Report forms for the drug and alcohol treatment project's seventeen facilities were reviewed on March 2, 2015. The project employs a total of 106 full-time counselors and counselor assistants. This number of full-time counselors and counselor assistants would require a minimum of 13 full-time clinical supervisors. The project currently employs 8 full-time clinical supervisors, as of March 2, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 physical plant inspection, the facility failed to keep frozen food at or below 0 degrees Fahrenheit in two of two freezers.
The findings include:
A physical plant inspection was conducted on March 24, 2015, at approximately 1:30 PM. During this time, it was reported that the kitchen staff read the temperature logs one time a day at the beginning of the day and prior to the start of breakfast preparations.
Freezer #1 is located in the kitchen, where only kitchen staff have access. The freezer temperature read 6 F at the time of inspection. After a review of the freezer temperature log for freezer #1, it was discovered that the freezer measured above 0 F in 14 out of 30 days in June 2014; 17 out of 31 days in July 2014; 22 out of 31 days in August 2014; 20 out of 30 days in September 2014; 21 out of 31 days in October 2014; 11 out of 30 days in November 2014; 18 out of 31 days in December 2014; 16 out of 31 days in January 2015; 9 out of 28 days in February 2015; and 16 out of 24 days (including the day of the inspection) in March 2015.
Freezer #2 is located in the dining area and is directly accessible by the clients. The freezer temperature read 1 F at the time of inspection. After a review of the freezer temperature log for freezer #2, it was discovered that the freezer measured above 0 F in 14 out of 31 days in July 2014; 19 out of 31 days in August 2014; 15 out of 30 days in September 2014; 22 out of 31 days in October 2014; 16 out of 30 days in November 2014; 15 out of 31 days in December 2014; 18 out of 31 days in January 2015; 15 out of 28 days in February 2015; and 11 out of 24 days (including the day of the inspection) in March 2015.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.63(a) LICENSURE Client record
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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes follow-up information and discharge summary in two of six client records reviewed.
The findings include:
Twenty-one client records were reviewed on March 24, 2015 through March 25, 2015. Six client records pertaining to inpatient short-term detoxification required a complete client record on an individual. The facility did not provide a complete client record for client records ,#1 and 6.
Client #1 was admitted to treatment on February 2, 2015 and was discharged on February 7, 2015. The facility failed to include documentation of a discharge summary in the client record as of the date of the inspection. In addition, the facility failed to include documentation of any follow-up information in the client record as of the date of this inspection.
Client #6 was admitted to treatment on February 17, 2015 and was discharged on February 23, 2015. The facility failed to include documentation of a discharge summary in the client record as of the date of the inspection. In addition, the facility failed to include documentation of any follow-up information in the client record as of the date of this inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which is to include follow-up information in three of six client records reviewed.
The findings include:
Twenty-one client records were reviewed on March 24, 2015 through March 25, 2015. Six client records pertaining to inpatient non-hospital residential required a complete client record on an individual. The facility did not provide a complete client record for client records, #2, 3, and 5.
Client #2 was admitted to treatment on January 27, 2015 and was discharged on February 24, 2015. The facility failed to include documentation of any follow-up information in the client record as of the date of this inspection.
Client #3 was admitted to treatment on October 1, 2014 and was discharged on November 1, 2014. The facility failed to include documentation of any follow-up information in the client record as of the date of this inspection.
Client #5 was admitted to treatment on January 30, 2015 and was discharged on February 5, 2015. The facility failed to include documentation of any follow-up information in the client record as of the date of this inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a) LICENSURE Client records
709.93. 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes follow-up information and an individualized treatment and rehabilitation plan in four of eleven client records reviewed.
The findings include:
Twenty-one client records were reviewed on March 24, 2015 through March 25, 2015. Eleven client records pertaining to outpatient required a complete client record on an individual. The facility did not provide a complete client record for client records, #16, 17, 18, and 19.
Client #16 was admitted to treatment on October 14, 2014 and was discharged on December 2, 2014. The facility failed to include documentation of any follow-up information in the client record as of the date of this inspection.
Client #17 was admitted to treatment on October 21, 2014 and was discharged on December 10, 2014. The facility failed to include documentation of any follow-up information in the client record as of the date of this inspection.
Client #18 was admitted to treatment on May 20, 2014 and was discharged on December 11, 2014. The facility failed to include documentation of any follow-up information in the client record as of the date of this inspection.
Client #19 was admitted to treatment on October 20, 2014 and was discharged on December 25, 2014. The facility failed to include documentation of a signed and dated individualized treatment and rehabilitation plan in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to document a physician signature on the individual treatment plans for medical assistance clients in two of two client records.
The findings included:
Twenty-one client records were reviewed on March 24, 2015 through March 25, 2015. Eleven of the client records were pertaining to the outpatient activity. Two of the eleven records reviewed were required to have a physician signature on the individual treatment plans. The individual treatment plans contained in client records, #11, and 19 did not contain a physician signature.
Client #11 was admitted to treatment on January 8, 2015 and was still an active client at the time of the inspection. The initial treatment and rehabilitation plan was developed and signed by the client on January 8, 2015 and a treatment plan update was signed/dated on January 16, 2015. Both the initial treatment plan and the treatment plan update did not include the physician's signature.
Client #19 was admitted to treatment on October 20, 2014 and was discharged on December 25, 2014. An initial treatment and rehabilitation plan was developed and signed by the client on October 20, 2014 that did not include a physician signature. Additionally, a treatment plan update was due to be signed and dated by the physician no later than December 20, 2015. The physician failed to sign and date a treatment plan update for client #19.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |