INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on July 12-13, 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:
As this was a provisional inspection conducted, not all regulations were reviewed. During future inspections, all regulations will be reviewed for compliance.
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Plan of Correction
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of May - July 2022 fire drill logs, the facility failed to document whether the fire alarm or smoke detector was operative during May and June 2022 fire drills.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinic Director, in the future, will check all boxes on the emergency drill form. The box which indicates whether the fire alarm or smoke detector was operative during the drill will be marked appropriately. The clinic director will ensure this deficiency will not happen again. |
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 April 17, 2022 through July 9, 2022, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients.
During the week of May 29 - June 4, 2022, the patient census was 667. The facility was required to provide at least 66.7 physician hours. There were 65.5 physician hours documented.
This is a repeat citation from the March 8, 2022 licensing inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinic Director will ensure that the Physician, Physician Assistant and/or Nurse Practitioner hours will meet the Pennsylvania regulation (715.6e) even during times of a national Holiday. The Clinic Director will ensure that his error does not happen again. |
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 hours per month of therapy during the third and fourth year of treatment in one out of three applicable records.
Patient #5 was admitted on May 19, 2021 and had a previous admission date of May 17, 2019. The client was still active at the time of the inspection. In April and May 2022, the patient had 30 minutes of individual therapy and zero hours of group therapy each month.
This is a repeat citation from the March 8, 2022 licensing inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All counselors under the direction of the Clinical Supervisor and Lead Counselor will ensure that patients on their caseload with 3 to 4 years of treatment, will complete 1 hour of therapy per month. the patient will complete more if it is indicated by their recovery needs. The clinical supervisor and lead counselor will monitor this issue through supervision. |
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 five applicable records reviewed.
Patient #4 was admitted on July 9, 2020 and was still active at the time of the inspection. The most recent annual evaluation was due no later than July 9, 2022; however, it was not completed at the time of the inspection.
Patient #5 was admitted on May 19, 2021 and was still active at the time of the inspection. The annual evaluation was due no later than May 19, 2022; however, it was completed on May 25, 2022.
Patient #10 was admitted on May 12, 2017 and discharged on June 16, 2022. The most recent annual evaluation was due no later than May 12, 2022; however, it was completed on May 19, 2022.
This is a repeat citation from the March 8, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This CD will monitor all annual physical examinations, including the annual reevaluation by the narcotic treatment physical, for promptness and completion before or on their annual due date. |
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 one out of five applicable records reviewed.
Patient #4 was admitted on July 9, 2020 and was still active at the time of the inspection. An annual evaluation was due no later than July 9, 2022; however, it was not completed at the time of the inspection.
This is a repeat citation from the March 8, 2022 licensing inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor and Lead Counselor will instruct the counselors during clinical supervision and group supervision to document and complete the patient's annual evaluation every year by the patient's anniversary date. The clinical supervisor and lead counselor will monitor these documents to ensure the annual clinical evaluations are being completed on time. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of patient records, the facility failed to document type and/or frequency of treatment services in patient individual treatment plans in seven out of ten records reviewed.
Patient #1 was admitted on April 19, 2022 and was still active at the time of the inspection. The comprehensive treatment plan dated May 23, 2022 did not include type and frequency.
Patient #2 was admitted on May 12, 2017 and discharged on June 16, 2022. The May 13, 2022 treatment plan update did not have frequency documented.
Patient #3 was admitted on June 15, 2022 and was still active at the time of the inspection. The June 16, 2022 treatment plan update did not have type and frequency documented.
Patient #4 was admitted on July 9, 2020 and was still active at the time of the inspection. The July 8, 2022 treatment plan update did not have frequency documented.
Patient #6 was admitted on August 30, 2019 and was still active at the time of the inspection. The June 29, 2022 treatment plan update did not have frequency documented.
Patient #8 was admitted on April 20, 2022 and was still active at the time of the inspection. The comprehensive treatment plan dated May 20, 202 did not have frequency documented.
Patient #9 was admitted on March 10, 2022 and was still active at the time of the inspection. The May 6, 2022 treatment plan update did not have frequency documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All counselors will complete the treatment plan with the patient and ensure that the treatment plan documents the type and/or frequency of treatment services. This will be monitored by the clinical supervisor and lead counselor as they review the treatment plan prior to approval. Any issues will be addressed with the individual counselor by the clinical supervisor or lead counselor immediately upon discovery and during monthly clinical supervision. |
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 ten records reviewed.
Patient #2 was admitted on May 12, 2017 and discharged on June 16, 2022. A treatment plan update was completed on January 10, 2022 and the next update was due no later than March 10, 2022; however, the next update was completed on May 13, 2022.
Patient #3 was admitted on June 15, 2020 and was still active at the time of the inspection. A treatment plan update was completed on March 3, 2022 and the next update was due no later than May 3, 2022; however, the next update was completed on June 16, 2022.
Patient #4 was admitted on July 9, 2020 and was still active at the time of the inspection. A treatment plan update was completed on January 11, 2022 and the next update was due no later than March 11, 2022; however, the next update was completed on May 10, 2022.
Patient #5 was admitted on May 19, 2021 and was still active at the time of the inspection. A treatment plan update was completed on March 14, 2022 and the next update was due no later than May 14, 2022; however, the next update was completed on May 16, 2022.
This is a repeat citation from the March 8, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor and lead counselor will instruct the counselor to complete patient treatment plans 60 days from the last treatment plan period in a timely manner. The clinical supervisor and lead counselor will monitor the counselor's progress on this issue during the individual clinical supervision and during the monthly group supervision. |