INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 29-30, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Discovery House CU- 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:
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide close supervision by a trained counselor or clinical supervisor for at least the first 6 months of employment.Employee #8 was hired on July 11, 2022 and was still employed at the time of the inspection. She had no documentation of close supervision.Employee #9 was hired on February 28, 2022 and was still employed at the time of the inspection. She had no documentation of close supervision. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will schedule close supervision for all counselor assistants for the first six months of their employment. Clinical Supervisor will schedule these supervisions in advance and share her calendar with Clinic Director so this can be monitored on a weekly basis. Clinic Director will then sign off on all supervisions each week to ensure completion of the supervision. Documentation of supervision will be filed in a binder and kept in Clinical Supervisors office.
Employee #8 and #9 have been scheduled for weekly close supervision starting 12/05/22 and will continue through 06/05/23. |
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 personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.Employee #7 was hired as a counselor on November 11, 2021 and was due to have the communicable disease trainings no later than November 11, 2022. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.This finding was reviewed with facility staff during the licensing inspection. This is a repeat citation from the December 1, 2021 licensing inspection.
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Plan of Correction
Clinical Supervisor will assist new employees in scheduling for HIV/AIDS and TB/STD upon their 30 day new employee orientation to Clearfield CTC. Clinical Supervisor will provide Clinic Director the identified dates to be monitored for completion.
Employee # 7 will have completed the communicable disease trainings no later than 3/31/23. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable client record.Client #6 was admitted on October 11, 2021 and discharged on June 7, 2022. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor and Clinic Director will develop a new client termination letter that will include the opportunity to request reconsideration of the decision terminating treatment in addition to referrals/contact information for other treatment providers. This letter will be provided and/or sent to all clients who are involuntary terminated from Clearfield CTC. This documentation will be utilized starting 12/05/2022. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in one out of five applicable records reviewed.Patient #6 was admitted on October 11, 2021 and was still active at the time of the inspection. In March 2022, the patient did not receive any individual psychotherapy sessions. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Primary counselors will limit the amount of times that a client is permitted to reschedule their individual psychotherapy sessions as a means to ensure each client is meeting this regulation. Primary Counselors will complete a deficiency report at the end of each month which will include those clients who did not receive individual psychotherapy and the reasoning why. This report will be reviewed by the Clinical Supervisor who will then schedule with that client in the beginning of the following month to schedule individual psychotherapy and ensure compliance. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to document an annual physical examination within the regulatory timeframe in one out of four applicable records.Patient #4 was admitted on October 8, 2021 and was still active at the time of the inspection. The annual physical examination was due no later than October 8, 2022; however, it was completed on October 10, 2022. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
CRNP's, Nurse Supervisor and Clinic Director will ensure that all annual physical examinations are done by the required due date. Nurse Supervisor, CRNP's and CD will utilize the alert system and place holds on clients 30 days prior to due date. Clinic Director will monitor this the beginning of each month to ensure compliance. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to document an annual clinical evaluation within the regulatory timeframe in one out of four applicable records. Patient #4 was admitted on October 8, 2021 and was still active at the time of the inspection. The annual physical examination was due no later than October 8, 2022; however, it was completed on October 28, 2022. This finding was reviewed with facility staff during the licensing inspection. This is a repeat citation from the December 1, 2021 licensing inspection.
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Plan of Correction
Clinical Supervisor will monitor annual clinical evaluations at the beginning of each month to ensure completion by identified due date. Counselors will identify and mark completed on their daily end of day checklist that is turned into the supervisor and reviewed for accuracy. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of five applicable records reviewed.Client #4 was admitted on October 8, 2021 and was still active at the time of the inspection. A treatment plan update was completed on March 30, 2022 and the next update was due no later than May 30, 2022; however, the next update was completed on June 17, 2022. Additionally, a treatment plan was completed on August 11, 2022 and the next update was due no later than October 11, 2022; however, the next update was completed on October 14, 2022.Client #6 was admitted on October 11, 2021 and discharged June 7, 2022. A treatment plan update was completed on February 9, 2022 and the next update was due no later than April 9, 2022; however, it was completed on April 13, 2022.Client #7 was admitted on July 22, 2019 and was still active at the time of the inspection. A treatment plan update was completed on July 18, 2022 and the next update was due no later than November 18, 2022; however, it was completed on November 22, 2022.Client #8 was admitted on February 2, 2021 and was still active at the time of the inspection. A treatment plan update was completed on April 1, 2022 and the next update was due no later than June 1, 2022; however, it was not completed until June 3, 2022.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor and Lead Counselor will monitor treatment plans and ensure they are completed by the identified due date. Clinical Supervisor will reiterate the importance of this in group supervision on a monthly basis with all clinical staff responsible for completing treatment plans. |