INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on December 5-6, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Discovery House HA 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:
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Plan of Correction
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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.
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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.
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Plan of Correction
Recruitment and hiring policy will be revised to address the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort will be made to hire staff persons representative of the population served. Program staff will continue to work with Human Resources Business Partner in the recruitment and hiring of appropriate staff for the project.
Completion Date:
1/15/2018 |
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
The facility failed to ensure that a counselor received at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics within the first year of employment in one of one personnel record reviewed on December 5-6, 2017.
Personnel record #8 was hired as a counselor on September 26, 2016. There was no documentation that the counselor had completed the 4 hours of tuberculosis sexually transmitted diseases and other health related topics, due by September 26, 2017, as of December 6, 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
STD,TB,HIV/AIDS training will be added to the new staff hire checklist to ensure all staff will be scheduled and trained within the first year of employment. The Clinical Director will review the checklist within the first 30 days of employment and monthly after to ensure training compliance. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
The facility failed to ensure that the FTE counselor caseload for counseling in an outpatient program did not exceed 35 active clients.
The Staffing Requirements Facility Summary Report form,completed by the facility, was reviewed on December 5-6, 2017. Five counselors caseloads exceeded the 35:1 active clients.
The five counselors caseloads were: 74:1, 37:1, 37:1, 42:1 and 42:1.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program staff will continue to work with Human Resources Business Partner in the recruitment and hiring of appropriate staff for the project and to ensure that the FTE counselor caseload for counseling in an outpatient program does not exceed 35 active patients. Program Director will be responsible for coordinating with Human Resources Business Partners for recruitment. Three qualified counselors have been interviewed and offered FTE positions to fulfill the 35:1 counselor patient ratio. Program Director will continue to actively interview and maintain a qualified pool of potential counselors to assure facility maintains a 35:1 ratio.
Clinical Supervisor, Senior Counselor, and Clinical Service Coordinator/CTC Division will meet monthly to review caseloads to assure facility maintains 35:1 ratio is met. |
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.
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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.
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Plan of Correction
Personnel policy will be revised to include the utilization of volunteers in the project. Program will review policy revision with all staff in the 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.
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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.
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Plan of Correction
Client Rights policy and procedure will be revised 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; clients have the right to submit rebuttal data or memoranda to their own record. Program management will review policy and procedure revisions with all staff at the January 2018 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.
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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.
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Plan of Correction
Unusual Incident policy and procedure will be revised 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 personnel on site. Policy and procedure will be revised to ensure that the revised policy and procedure of reporting an unusual incident to an entity is in full compliance with State confidentiality laws. Program management will review policy and procedure revisions with all staff at the January 2018 staff meeting. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
The facility failed to verify that the individual had reached 18 years of age in four of nine patient records reviewed on December 5-6, 2017,
There was no documentation that verified the age of the patient in patient records # 1, 10, 11 and 12.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will provide a training to clinical staff addressing the appropriate screening to determine eligibility for admission. The verification process will include the individual's identity, including name, address, date of birth, emergency contact, and other identifying data. The Clinical Supervisor will monitor admission process to assure accuracy before individual is admitted into program quarterly. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to verify the individual's identity in four of nine patient records reviewed on December 5-6, 2017,
There was no documentation that verified the identity of the patient in patient records # 1, 10, 11 and 12.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director provided a training to clinical staff addressing the appropriate screening to determine eligibility for admission. The verification process will include the individual's identity, including name, address, date of birth, emergency contact, and other identifying data. The Clinical Supervisor will monitor admission process to assure accuracy before individual is admitted into program quarterly. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to document that each female patient was fully informed of the possible risk to her or her unborn child in two of nine patient records reviewed on December 5-6, 2017.
Thirteen patient records were reviewed. Ten records were reviewed as methadone patients and three were reviewed as buprenorphine waiver patients.
There was no documentation in patient records # 5 and 15 that the female patient was informed of the risks.
These finding were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Patient Pregnant Acknowledgement of Risks Form has been added to the intake process checklist. Counselors will be responsible for assuring new pregnant female patients are educated on the risks of MAT and pregnancy. New patients will review and acknowledge the information with their signature on the form. Clinical Supervisor will review new admissions intake process checklist 24 hours after admission for compliancy. Program Director will review new admission process quarterly to assure compliancy. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
The facility failed to document a complete initial drug-screening urinalysis for each prospective patient in six of thirteen patient record reviewed on December 5-6, 2017.
Thirteen patient records were reviewed. Ten were reviewed as methadone patients and three were reviewed as buprenorphine waiver patients. Patient records # 1, 3, 4, 11, 12 and 15 did not document a completed drug screen prior to admittance.
Patient # 1 was admitted and dosed on July 19, 2017. The initial drug-screening urinalysis results were documented on July 20, 2017.
Patient # 3 was admitted and dosed on March 20 , 2017. There was no reported date on the initial drug-screening urinalysis.
Patient # 4 was admitted and dosed on January 4, 2017. The initial drug-screening urinalysis results were documented on January 6, 2017.
Patient # 11 was admitted and dosed on February 1, 2017. The initial drug-screening urinalysis results were documented on February 19, 2017.
Patient # 12 was admitted and dosed on December 16, 2016. The initial drug-screening urinalysis results were documented on December 20, 2016.
Patient # 15 was admitted on January 25, 2017 and received a script for Suboxone on January 30, 2017. There was no date of report documented on the initial drug-screening urinalysis.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The medical staff at this facility will complete all urine drug screening and send to an approved laboratory for testing and receiving results. This will include initial and monthly drug screening urinalysis in the bupernorphine program. Counselor will be required to assure patient has urinalysis testing during the assessment process to be sent to the approved laboratory the day of assessment. Nurse Manager will be responsible to assure patients urinalysis results are present with a report date before patient will be admitted into program. Clinical Supervisor will review new admission records within 24hours after admission and monthly thereof for compliancy. |
715.14(d) LICENSURE Urine testing
(d) A narcotic treatment program shall ensure that a laboratory that performs the testing required under this section shall be in compliance with applicable Federal requirements, specifically the Clinical Laboratory Improvement Amendments of 1998 (42 U.S.C.A. §§ 201 note, 263 and 263a notes), and State requirements, specifically the Pennsylvania Clinical Laboratory Act (35 P.S. §§ 2151-2165) and Chapter 5 (relating to clinical laboratories).
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Observations
The facility failed to ensure that the laboratory that performed the testing complied with the Clinical Laboratory Improvement Amendments of 1998 as reviewed on December 5-6, 2017.
The facility did not provide documentation that the laboratory used was CLIA approved.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility will ensure the laboratory that performs the urinalysis testing is in compliance with the Clinical Laboratory Improvement Amendments of 1988. The facility will secure documentation that the laboratory is CLIA approved. The Program Director will be responsible for ensuring the laboratory that performs the urinalysis testing is in compliance with the Clinical Laboratory Improvement Amendments of 1988. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The facility failed to provide a patient with at least 1 hour of group or individual psychotherapy every 2 months in one of two patient records reviewed on December 5-6, 2017.
Patient # 8 requires 1 hour of group or individual psychotherapy every 2 months. The last two documented sessions were May 24, 2017 and November 23, 2017. No sessions were documented for July or September 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will provide a training to clinical staff addressing the requirements for individualized psychotherapy services. The requirements would consist of 2.5 hours of psychotherapy per month during the patient's first 2 years, 1 hour of individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing patient assessments. The Program Director and Clinical Supervisor will review for compliance quarterly. |
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.
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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.
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Plan of Correction
Transfer policy and procedure will be revised to include the project will transfer a patient within 7 days of the patients request to be transferred. Program management will review policy and procedure revisions with all staff at the January 2018 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.
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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.
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Plan of Correction
Termination policy and procedure will be revised to include a patient may be involuntarily discharged from the project if the patient has failed to follow treatment plan objectives. Program management will review policy and procedure revisions with all staff at the January 2018 staff meeting. |