INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on March 8, 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 - 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 this inspection:
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Plan of Correction
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of fire drill logs from January 2021 through February 2022, the facility failed to prepare alternate exit routs to be used during fire drills. Documentation on all the logs showed the main door, side door and breakroom door were used every month. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Monthly Fire Drills will be conducted by the Clinic Director. The drills will have a variety of situations that will mimic an actual emergency. Throughout the year 2022 and moving forward, our staff will be informed during the drill that an exit is not available due to an imaginary fire in that area. In our fire drill, immediately after the state survey, on March 30, 2022, the staff was informed that an exit could not be used due to an imaginary fire in the area. This practice will continue. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of patient records, the facility failed to keep disclosures of patient identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one out of nine records reviewed. Patient #2 was admitted on October 19, 2021 and was still active at the time of the inspection. A consent to release form was signed and dated on January 25, 2022 to a government agency that allowed for the release of urine analysis screenings. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
During group supervision on March 14, 2022, the Clinical Supervisor and Lead Counselor informed each counselor that urinalysis is not to be released to agencies, government, or otherwise. The entire clinical staff reviewed the CFR part 42 regulations.
On Monday, April 11, 2022, this Clinic Director informed all staff that Urinalysis will not be sent to agencies including government agencies, even with patient consent.
Starting April 11, 02022 internal audits will be performed by the Clinical Supervisor and the Lead Counselor on releases completed by counselors to eliminate all breaches of confidentiality. |
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 a review of patient records, the facility failed to notify the patient, in writing, of the facility's decision to involuntarily terminate the patient in one out of one applicable records reviewed.Patient # 6 was admitted April 7, 2015 and discharged on September 13, 2021. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On April 1, 2022, This Clinic Director will monitor this process to ensure that all administrative involuntary discharges will receive a letter via the US mail. This Clinic Director informed our management staff that involuntary termination of a patient required a letter informing the patient of their termination from treatment.
In the future, this CD will send a letter through the U.S. mail system to all patients being involuntarily terminated from treatment. This letter will include a message stating that they have the right to appeal the decision. A copy of this letter will be scanned into the patient's chart along with other discharge documentation. As pf 04/11/2022 the management staff was informed on how to proceed with this issue. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of physician timesheets from October 3, 2021 through December 18, 2021, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients. During the week of October 3-9, 2021, the patient census was 658. The facility was required to provide at least 65.8 physician hours. There were 64.5 physician hours documented. During the week of October 10-16, 2021, the patient census was 666. The facility was required to provide at least 66.6 physician hours. There were 65 physician hours documented. During the week of October 17-23, 2021, the patient census was 670. The facility was required to provide at least 67 physician hours. There were 65 physician hours documented. During the week of October 24-30, 2021, the patient census was 669. The facility was required to provide at least 66.9 physician hours. There were 66 physician hours documented. During the week of October 31 - November 6, 2021, the patient census was 665. The facility was required to provide at least 66.5 physician hours. There were 65 physician hours documented.During the week of November 7 - 13, 2021, the patient census was 662. The facility was required to provide at least 66.2 physician hours. There were 66 physician hours documented. During the week of November 14-20, 2021, the patient census was 666. The facility was required to provide at least 66.6 physician hours. There were 60.5 physician hours documented. During the week of November 28-December 4, 2021, the patient census was 667. The facility was required to provide at least 66.7 physician hours. There were 58 physician hours documented. During the week of December 5-11, 2021, the patient census was 664. The facility was required to provide at least 66.4 physician hours. There were 65.75 physician hours documented. During the week of December 12-18, 2021, the patient census was 660. The facility was required to provide at least 66 physician hours. There were 62.5 physician hours documented. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of March 9, 2022, this CD will ensure that the medical director will meet the 715.6d Pennsylvania regulations by having the Physician hours increased to meet the changes in our census. The physician will provide 1 hour to every 10 patients as indicated by the Pennsylvania State regulations on Physician staffing. This CD will monitor the physician hours and the census closely so that the regulations on the physician to patient ratio are met. |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on the observation of medication administration, the facility failed to properly verify the correct identity of a patient prior to administration of an agent. Section 6.1.1, #7d of the facility's policy and procedures manual states "patients will present at the dispensing window without hats or sunglasses. There were nine observed occurrences where the patient was not asked to remove their hat prior to dosing. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our nursing staff will endure that any patient wearing a hat will be asked to remove the hat prior to medicating. This will ensure the proper identification of each patient. Our nurse supervisor will monitor each nurse for progress and will keep this Clinic Director informed of any challenges in this area. |
715.14(b) LICENSURE Urine testing
(b) A narcotic treatment program shall develop and implement policies and procedures to ensure that urine collected from patients is unadulterated. These policies and procedures shall include random observation which shall be conducted professionally, ethically and in a manner which respects patient privacy.
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Observations
Based on direct observation of urinalysis collection procedures, the facility failed to follow their policy and procedures manual to ensure that urine collected from patients is unaltered. Policy 5.12.1 states the staff person will use appropriate temperature tools to ensure specimen is appropriate temperature. Temperature tools were not used during one patient's urine collection process. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The nursing staff will utilize the laser temperature gauge to monitor the temperature of urine samples. This will avoid the possibility of the adulteration of the urine specimen. On April 4, 2022 this Clinic Director and the nurse supervisor ordered two additional temperature guns so that each nurse will have a temperature gun at their individual nursing station. The CNC4470 Gun,Traceable,IR,Thermometer has been ordered from Medline Company.
The nurse supervisor will monitor the appropriate use of these instruments. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on direct observation of medication administration, the facility failed to follow 6.1.1.7i of the facility's policy and procedures manual requiring patients to speak following receiving their medication dose. Two patients were not required to speak after receiving their dose. In addition, the facility failed to administer medication in a manner that protects the patient from disruption or annoyance from other individuals. The waiting line to receive medication was observed to be directly behind the patient's receiving their dose.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On April 9, 2022, the nursing staff has been informed of the appropriate procedures after dosing a patient. The nurse supervisor will monitor the nursing staff's progress in this area. All patients will be asked to speak immediately after dosing and prior to leaving the view of the dosing nurse.
The waiting line where the patients receive their medication has a door, which will remain closed to all other patients who are not dosing at the time. In addition to the door remaining closed, a buzzer system has been installed, which will alert the patients in line when to enter the dosing area. |
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 patient with 2.5 hours of psychotherapy per month during the patient's first two years of treatment in two out of two applicable records. Patient #2 was admitted on October 19, 2021 and was still active at the time of the inspection. In December 2021, the patient had one hour of individual and 1.25 hours of group therapy. Patient #4 was admitted on November 2, 2021 and was still active at the time of the inspection. In December 2021, January 2022 and February 2022, the patient had 30 minutes of individual therapy each month and zero hours of group therapy. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Patient # 2 left the group early due to a personal issue. On April 14, 2022, in the next clinical supervision group, the clinical supervisor and lead counselor will inform the counselors to reschedule another group or an individual session for patients who leave the group early.
Patient #4 is a transfer from Las Vegas with more than 12 years of consecutive treatment. There will be clearer documentation of a patient's transfer from another facility showing the patient's years of MAT treatment. The staff will not rely on documented phone conversations as an indication of a patient's history in treatment. On April 12, 2022 this CD has spoken to the Clinical Supervisor regarding this issue. |The counselor's charts will be audited regularly to eliminate the chances of either of these issues happening again.
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715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. 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 one hour per month of therapy during the third and fourth year of treatment in one out of one applicable record.Patient #1 was admitted on January 11, 2019 and was still active at the time of the inspection. In January 2022, the patient had 30 minutes of individual therapy and zero hours of group therapy.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This patient completed a half-hour of individual counseling, then completed a face-to-face Annual Clinical Evaluation totaling 1.0 hours of clinical service. This CD and Clinical Supervisor has informed the counselors that the Annual Clinical Evaluation is in addition to the counseling session. On April 4, 2022, the clinical supervisor and lead counselor informed the counselors not to include the Annual Clinical Evaluation as a part of the counseling session. On April 14, 2022, during the clinical supervision group session, each counselor will be instructed to complete the Annual Clinical Evaluation in addition to the hour of individual counseling. The clinical supervisor and lead counselor will monitor the patient's annual services to ensure this has been corrected. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to document transfer of patient files to the patient's new treatment facility in one out of one applicable record. Patient #7 transferred to another treatment facility on January 18, 2021 and returned on February 11, 2021. Patient is an active client at the time of the inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This CD and the Clinical Supervisor will oversee all intake and transfer processes, where a patient is being transferred into or out of our facility. The clinical supervisor will review with counseling staff the proper procedure for transferring a patient to another treatment facility, on April 14, 2022. This review will take place during the Clinical Supervision group. This CD has met with the intake staff and reviewed the appropriate State mandated regulations for receiving a transferring patient, personally. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document notification to previous treatment facility of patient's admission in one out of one applicable record. Patient #7 was admitted as a transfer from another treatment facility on February 11, 2021 and is still active at the time of the inspection. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Patient #7 was transferred to another DH facility. Information regarding the transfer was given and a transfer acknowledgment was sent to the receiving facility. However, the transfer acknowledgment was not placed in the scanned documents. On March 9, 2022, This CD informed the intake staff of the importance of immediately faxing and then scanning the transfer acknowledgments in the patient's charts. The clinical supervisor and the Lead counselor will monitor patient transfers to ensure proper procedures will be followed. |
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 medical evaluation in three out of six applicable records. Patient #1 was admitted on January 11, 2019 and was still active at the time of the inspection. The most recent annual evaluation was due no later than January 11, 2022; however, it was completed on January 27, 2022. Patient #6 was admitted on April 7, 2015 and discharged on September 13, 2021. The most recent annual evaluation was due no later than April 7, 2021; however, it was completed on April 30, 2021.Patient #8 was admitted on February 7, 2019 and discharged on March 1, 2021. The most recent annual evaluation was due no later than February 7, 2021; however, it was completed on February 15, 2021.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Medical Director and the Nurse Practitioner will notify the patient weeks prior to their annual physical examinations. This will give the patient time to reschedule their appointment if necessary. This will time for the postponing of the scheduled examination., yet still meet the required due date. This CD will monitor the progress or any challenges the NP or medical director may be having. This CD will also put give reminders to the staff when a patient's annual services are due. |
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 in four out of six applicable records.Patient #3 was admitted on February 3, 2021 and was still active at the time of the inspection. An annual evaluation was due no later than February 3, 2022; however, it was completed on February 17, 2022. Patient #4 was admitted on November 2, 2020 and was still active at the time of the inspection. An annual evaluation was due no later than November 2, 2021; however, it was not documented as of the date of the inspection. Patient #6 was admitted on April 7, 2015 and discharged on September 13, 2021. The most recent annual evaluation was due no later than April 7, 2021; however, it was completed on April 28, 2021. Patient #7 was admitted on February 11, 2021 and was still active at the time of the inspection. An annual evaluation was due no later than February 11, 2022; however, if was completed on February 17, 2022.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On April 4, 2022, this clinic director instructed the Clinical Supervisor and Lead Counselor will monitor all Annual Clinical Evaluations by completing internal audits on the patient charts. They will monitor the completion of the Annual clinical Evaluations to review the quality of the note and the completion of the dates. This CD will meet with the Clinical supervisor and the Lead Counselor to address their progress in this area. |
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 patient records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of nine records reviewed.Patient #1 was admitted on January 11, 2019 and was still active at the time of the inspection. A treatment plan update was completed on July 10, 2021 and the next update was due no later than September 10, 2021; however, the next update was completed on November 11, 2021. Patient #4 was admitted on November 2, 2020 and was still active at the time of the inspection. A treatment plan update was completed on September 18, 2021 and the next update was due no later than November 18, 2021; however, it was completed on January 6, 2022.Patient #6 was admitted on April 7, 2015 and discharged on September 13, 2021. A treatment plan update was completed on April 7, 2021 and the next update was due no later than June 7, 2021; however, it was completed on August 6, 2021.Patient #9 was admitted on June 11, 2021 and was still active at the time of the inspection. A treatment plan update was completed on July 28, 2021 and the next update was due no later than September 18, 2021; however, it was not completed until October 4, 2021.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This CD met with the Clinical Supervisor and the Lead Counselor on April 4, 2022, regarding the updating of the treatment plans. Treatment plans will be completed with the patient every 60 days due to their instability. However, patients who are in the maintenance phase of treatment may have their treatment plans updated every 120 days as approved by the state of Pennsylvania guidelines. This CD and the Clinical Management team will monitor the progress on this issue by completing audits on the patient treatment plans. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of patient records, the facility failed to ensure that the patients received counseling services according to their individual comprehensive treatment plan in four out of nine records reviewed.Patient #1 was admitted on January 11, 2019 and was still active at the time of the inspection. A treatment plan, dated November 11, 2021, indicated 1.5 hours per month of group sessions and one hour per month of an individual session. The record of service and progress notes indicated that the patient received one hour of individual therapy in December 2021 and February 2022, and 30 minutes of individual therapy in January 2022. There were no documented group sessions in December 2021 through February 2022. Patient #2 was admitted on October 19, 2021 and was still active at the time of the inspection. A treatment plan dated November 19, 2021 indicated one hour of individual and 1.5 hours of group therapies each month. In December 2021, the patient received one hour of individual and 1.25 hours of group therapy. Patient #5 was admitted was admitted on November 17, 2021 and was still active at the time of the inspection. A treatment plan dated December 17, 2021 indicated one hour of therapy each month. In December 2021 through February 2022, the patient received 30 minutes of therapy during each of those months. Patient #6 was admitted was admitted on April 7, 2015 and discharged on September 13, 2021. Treatment plans dated April 7, 2021 and August 6, 2021 indicated one hour of individual and 1.5 hours of group therapies each month. During June 2021 through August 2021, the patient received 30 minutes of individual therapy each month with one documented no show in August 2021. There were no documented group sessions for the months of June, July and August 2021. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On | April 4, 2022, this CD met with the Clinical Supervisor and the Lead counselor regarding counseling hours documentation in the treatment. In the future when completing the treatment plan, the counselor will indicate the correct amount of counseling time for the individual patient's treatment needs. The Clinical Supervisor and the Lead Counselor will monitor the treatment plans closely so that the patient will know the minimum amount of counseling for his or her recovery needs. |