INITIAL COMMENTS
|
This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on January 3-4, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Discovery House-NC, 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 the inspection:
|
Plan of Correction
|
704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
|
Observations
The facility failed to document a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served and that every effort will be made to hire staff persons representative of that population.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Recruitment and Hiring Policy will be updated by the Clinical Services Department, and Clinical Director will oversee this process. This policy will be updated by 1/15/2018. Every effort will be made to hire staff persons representative of the population served. Program Staff will continue to work with the Human Resources Business Partner in the recruitment and hiring of appropriate staff of the project. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
|
Observations
The facility failed to have written project policies and procedures regarding the utilization of volunteers.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Personal Policy will be revised to include the utilization of volunteers in the project. Clinical Services Department will be responsible for updating the policy, and Clinic Director will oversee this process. Policy will be updated by 1/15/18. Clinic Director will review the policy revision with all staff in January All Staff Meeting. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
The facility failed to document written policies and procedures regarding all of the client rights.
The policy and procedures manual and client handbook were reviewed. Neither the policy manual nor the client handbook documented 709.30 (4) Clients have the right to appeal a decision limiting access the their records to the director, (5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, or
(6) Clients have the right to submit rebuttal data or memoranda to their own record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Services Department will updated the Client Rights Policy and Procedure to include the client's right to appeal a decision limiting access to records to the director; clients having the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records; and clients having the right to submit rebuttal data or memoranda to their own record. Clinic Director will oversee this process, and will review the updated policy and procedure with all staff in the January All Staff Meeting. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
|
Observations
The facility failed to develop and policies and procedures to respond to the following unusual incidents:
709.34 (a)
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
(b) (5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State confidentiality laws.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Services Department will revise the Unusual Incident Policy and Procedure to include how the project will report and respond to a significant disruption of services due to a disaster such as fire, storm flood, or other occurrence which closes the facility for more than one day, including if the project requires the presence of police, fire or ambulance personal on site.
Policy and Procedure will also be revised by the Clinical Services Department to ensure that the reporting of an unusual incident to an entity is in full compliance with State Confidentiality laws.
Policy revisions will be completed by the Clinical Services Department by 1/15/18. Clinic Director will review these policy and procedure revisions with all staff in the January 2018 All Staff Meeting. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
The facility failed to document that a written unusual incident report was filed with the Department for unusual incident reports reviewed on January 3-4, 2018.
An ambulance was on site on 11/2/17.
The police were on site on 9/21/17.
There was no documentation provided that the incidents had been filed with the Department.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
During All Staff Meeting held 1/9/18 the regulation was reviewed in regards to the Unusual Incident Reporting. Everyone is aware if an Unusual Incident occurs and Police or ambulance are called to the facility upon completing the Unusual Incident Report the report needs to be reported to the State that day and a fax transmittal with it to show the Unusual Incident was sent. Program Director will be responsible to see all staff comply with the regulation and see the Unusual Incident reports are sent to the state in a timely manner |
715.20 LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
|
Observations
The facility failed to develop complete written transfer policies and procedures.
The policy and procedure manual was reviewed. The policies and procedures did not include that the facility would transfer the patient within 7 days of the request of the patient and 715.20(4).
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Services Department will revise the Transfer Policy and Procedure to include that the project will transfer a patient within 7 days of the patient's request to be transferred. Clinic Director will review policy and procedure revisions with all staff in January 2018 All Staff Meeting. |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
|
Observations
The facility failed to develop policies which included 715.21 (1) (iv).
The policy and procedures manual was reviewed. The policy did not include that a patient may be involuntarily discharged if the patient has failed to follow treatment plan objectives.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Services Department will revise the Termination Policy and Procedure to include that a patient may be involuntarily discharged from the project if the patient has failed to follow treatment plan objectives. Program Management will review these policy and procedure revisions with all staff in the January 2018 All Staff Meeting. |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
|
Observations
The facility failed to document an aftercare plan in one of one client record reviewed on January 3-4, 2018.
Client # 11 was successfully discharged on October 31, 2017. There was no documentation provided of an aftercare plan.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinical Supervisor reviewed the citation on Aftercare plans. All clinicians were made aware to complete the after care plan. This was done at the All Staff meeting held on 1/9/18. Clinical Supervisor and lead counselor will do chart audit to ensure compliance. |