INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 23-25, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House Pa 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 and a plan of correction is due on December 29, 2009.
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Plan of Correction
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705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
Based on the review of the facility's written procedures for the evacuation and transfer of clients and staff to a safe location, the facility failed to document an emergency procedure which identified a safe location within the building.
The findings included:
The written procedure for emergencies did not identify and address a safe location within the building when external emergencies prohibit the evacuation of the building.
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Plan of Correction
A written procedure will be included in our emergency action plan that will identify and address a safe location within the building when external emergencies prohibit the evacuation of the building. The Program Director will be responsible for creating this addendum. This will be in place by 01/15/10. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of fiscal documents presented at the time of the inspection and an interview with the facility director, the facility failed to document an annual audit of financial activities for the year ended 12/31/08.
The findings included:
During the onsite licensing inspection conducted from November 23 to 25, 2009, the fiscal documents were reviewed. The certified public accountant's dated and signed comments at the beginning of the fiscal document indicated that the document was not an audit. The facility director was interviewed about the documentation of the annual audit which included the opinion of the accountant and confirmed that this was the only fiscal document available for review.
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Plan of Correction
Discovery House will conduct an audit for FY 2010. We will submit a 2009 compellation review and an engagement letter for 2010. Director will monitor for compliance. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on the results of the physical plant inspection, the facility failed to ensure that client records containing client identifying information were secured within locked storage containers.
The findings included:
During the physical plant inspection completed on 11/23/ 2009, several cardboard boxes containing client identifying information were observed to be stacked in the rear room near the fire exit. The records were not secured within a locked storage container and were located in an unlocked and unmonitored area of the building.
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Plan of Correction
We will ensure that all client records containing client identifying information will be secured within locked storage containers. Program Director will monitor for full compliance. This will be immediate and on-going. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records the facility failed to ensure that consents to release information to health and hospital plans, insurance companies and other third party payers; criminal justice entities and government officials were in compliance with the limitations imposed at 4 Pa. Code subsection 255.5(b) five of the twenty client records reviewed.
The findings included:
Twenty client records were reviewed during the onsite licensing inspection conducted from November 23 through 25, 2009. Consents to release information forms which permitted the release of information that exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b) for releases of information to third party payers and government entities were documented in five of the client records reviewed. The facility director was interviewed on November 24 and 25, 2009 and he could not confirm that the information was not released based on the information listed on the consent to release information forms.
Client # 9 was admitted on 7/18/09. Consent to release information forms permitting the release of information to the client's probation officer listed the specific information to be released as the client's medication history, treatment plans and current methadone dosing levels. All of these components exceed the limitations imposed at 4 Pa. Code Subsection 255.5(b).
Client # 10 was admitted on 9/10/08. Consent to release information forms permitting the release of information to the client's third party payer listed the specific information to be released as the client's medication history, treatment plans, and the methadone dosing levels. A consent to release information to government officials permitted the release of the client's medication histories and drug test results. All of these components exceed the limitations imposed at 4 Pa. Code Subsection 255.5(b).
Client # 11 was admitted on 1/22/09. Consent to release information forms permitting the release of information to the client's third party payer listed the specific information to be released as the client's medication history, treatment plans, methadone dosing levels and drug test results. All of these components exceed the limitations imposed at 4 Pa. Code Subsection 255.5(b).
Client # 13 was admitted on 12/3/08. Consent to release information forms permitting the release of information to the client's third party payer listed the specific information to be released as the client's treatment plans and methadone dosing levels. All of these components exceed the limitations imposed at 4 Pa. Code Subsection 255.5(b).
Client # 14 was admitted on 12/8/08. Consent to release information forms permitting the release of information to the client's third party payer listed the specific information to be released as the client's treatment plans. This exceeds the limitations imposed at 4 Pa. Code Subsection 255.5(b).
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Plan of Correction
Our Clinical Supervisor conducted an in-house training on Confidentiality and Consents to release information. This training was held on 12/01/09. Each counselor will review their patient's records by the end of December, 2009 and make the appropriate changes to all Consents. The Clinical Supervisor will review the Consents in supervision with each counselor and will continue to do quality reviews of all Confidentiality issues on a monthly basis to ensure compliance with State Regulations concerning Confidentiality and Consents to release information. Counselors will be sent to confidentiality training as needed and will continue to follow up on this issue in our monthly clinical meetings. The Clinical Supervisor will monitor for compliance. This will be immediate and on-going. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client record documentation, the facility failed to document the evaluation of coping mechanisms, support systems and clinical impressions on the psychosocial evaluations in 16 of 20 client records.
The findings included:
Twenty client records were reviewed during the onsite inspection of November 23 through 25, 2009. Several components of the psychosocial evaluation were missing from 16 of 20 client records reviewed.
The psychosocial evaluation in client record # 1 did not include evaluations of coping mechanisms and clinical impressions which identified possible relationships, conditions and causes leading to the client's current situation as of 11/25/09. The client was admitted on 6/3/09 and the psychosocial evaluation was dated 6/3/09.
The psychosocial evaluation in client record # 2 did not include evaluations of coping mechanisms, support systems and clinical impressions which identified possible relationships, conditions and causes leading to the client's current situation as of 11/25/09. The client was admitted on 8/4/09 and the psychosocial evaluation was dated 8/4/09.
The psychosocial evaluation in client record #5 did not document clinical impressions which identified possible relationships, conditions and causes leading to the client's current situation as of 11/25/09. The client was admitted on 8/24/09 and the psychosocial evaluation was dated 8/24/09.
The psychosocial evaluation in client record # 6 did not include evaluations of coping mechanisms and support systems as of 11/25/09. The client was admitted on 6/17/09 and the psychosocial evaluation was dated 6/17/09.
The psychosocial evaluation in client record # 7 did not include evaluations of coping mechanisms and clinical impressions which identified possible relationships, conditions and causes leading to the client's current situation as of 11/25/09. The client was admitted on 6/10/09 and the psychosocial evaluation was dated 6/10/09.
The psychosocial evaluation in client record # 8 did not include evaluations of coping mechanisms and clinical impressions which identified possible relationships, conditions and causes leading to the client's current situation as of 11/25/09. The client was admitted on 6/9/09 and the psychosocial evaluation was dated 6/9/09.
The psychosocial evaluation in client record # 11 did not include evaluations of coping mechanisms, support systems and clinical impressions which identified possible relationships, conditions and causes leading to the client's current situation as of 11/25/09. The client was admitted on 1/22/09 and the psychosocial evaluation was dated 1/22/09.
The psychosocial evaluation in client record # 12 did not include evaluations of support systems and clinical impressions which identified possible relationships, conditions and causes leading to the client's current situation as of 11/25/09. The client was admitted on 5/4/09 and the psychosocial evaluation was dated 5/4/09.
The psychosocial evaluation in client record # 13 did not include evaluations of coping mechanisms and clinical impressions which identified possible relationships, conditions and causes leading to the client's current situation as of 11/25/09. The client was admitted on 12/23/08 and the psychosocial evaluation was dated 12/23/08.
The psychosocial evaluation in client record # 14 did not include evaluations of coping mechanisms and clinical impressions which identified possible relationships, conditions and causes leading to the client's current situation as of 11/25/09. The client was admitted on 12/8/08 and the psychosocial evaluation was dated 12/8/08.
The psychosocial evaluation in client record # 15 did not include evaluations of coping mechanisms and support systems as of 11/25/09. The client was admitted on 6/24/09 and the psychosocial evaluation was dated 6/24/09.
The psychosocial evaluation in client record # 16 did not include evaluations of coping mechanisms and support systems as of 11/25/09. The client was admitted on 7/17/09 and the psychosocial evaluation was dated 7/17/09.
The psychosocial evaluation in client record # 17 did not include evaluations of coping mechanisms and support systems as of 11/25/09. The client was admitted on 10/20/09 and the psychosocial evaluation was dated 10/20/09.
The psychosocial evaluation in client record # 18 did not include evaluations of coping mechanisms and support systems as of 11/25/09. The client was admitted on 9/17/09 and the psychosocial evaluation was dated 9/17/09.
The psychosocial evaluation in client record # 19 did not include evaluations of coping mechanisms, support systems and clinical impressions which identified possible relationships, conditions and causes leading to the client's current situation as of 11/25/09. The client was admitted on 8/18/09 and the psychosocial evaluation was dated 8/18/09.
The psychosocial evaluation in client record # 20 did not include an evaluation of coping mechanisms as of 11/25/09. The client was admitted on 3/11/09 and the psychosocial evaluation was dated 3/17/09.
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Plan of Correction
Our Clinical Supervisor will conduct an in-house training on the Psychosocial evaluation. This training will be held on 01/04/10. The Clinical Supervisor will review the Psychosocial evaluations in supervision with each counselor and will continue to do clinical/medical audits within 14 days of admission to ensure compliance with State Regulations concerning the psychosocial evaluations. |
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 client records, the facility failed to document the type and frequency of treatment on the treatment plans nine of twenty client records.
The findings included:
Twenty client records were reviewed on November 23, 24 and 25. The type and/or frequency of treatment to be provided was not documented on the treatment plans in nine of twenty client records.
Client # 6 was admitted on 7/18/09. The facility failed to document the type of service to be provided to the client on the treatment plan dated 8/19/09.
Client # 9 was admitted on 6/17/09. The facility failed to document the type and frequency of service to be provided to the client on the treatment plan dated 7/20/09.
Client # 10 was admitted on 9/10/08. The facility failed to document the type of service to be provided to the client on the treatment plan dated 10/20/08.
Client # 11 was admitted on 1/22/09. The facility failed to document the type of service to be provided to the client on the treatment plan dated 2/23/09.
Client # 12 was admitted on 5/4/09. The facility failed to document the type of service to be provided to the client on the treatment plan dated 5/29/09.
Client # 13 was admitted on 12/3/08. The facility failed to document the type of service to be provided to the client on the treatment plan dated 1/7/09.
Client # 15 was admitted on 6/24/09. The facility failed to document the type of service to be provided to the client on the treatment plan dated 7/9/09.
Client # 17 was admitted on 10/20/09. The facility failed to document the type of service to be provided to the client on the treatment plan dated 11/23//09.
Client # 18 was admitted on 9/17/09. The facility failed to document the type of service to be provided to the client on the treatment plan dated 10/17/09.
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Plan of Correction
Our Clinical Supervisor will conduct an in-house training on individual Treatment Plans. This training will be held on 01/04/10. The Clinical Supervisor will review the Treatment Plans in supervision with each counselor and will continue to do quality reviews on a monthly basis. Clinical Supervisor will monitor for compliance. This will be immediate and on-going. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document the proposed type of support services to be offered on the treatment plans in 11 of 20 client records.
The findings included:
Twenty client records were reviewed on November 23, 24 and 25 , 2009. There was no documentation of support services on the treatment plans in 11 of 20 client records.
Client # 1 was admitted on 6/30/09. The facility failed to document the proposed support services on the treatment plan dated 7/2/09.
Client # 2 was admitted on 8/4/09. The facility failed to document the proposed support services on the treatment plan dated 9/15/09.
Client # 4 was admitted on 5/3/07. The facility failed to document the proposed support services on the treatment plan dated 6/29/07.
Client # 5 was admitted on 8/24/09. The facility failed to document the proposed support services on the treatment plan dated 9/26/09.
Client # 7 was admitted on 6/10/09. The facility failed to document the proposed support services on the treatment plan dated 7/15/09.
Client # 11 was admitted on 1/22/09. The facility failed to document the proposed support services on the treatment plan dated 2/23/09.
Client # 15 was admitted on 6/24/09. The facility failed to document the proposed support services on the treatment plan dated 7/9/09.
Client # 16 was admitted on 7/17/09. The facility failed to document the proposed support services on the treatment plan dated 7/31/09.
Client # 18 was admitted on 9/17/09. The facility failed to document the proposed support services on the treatment plan dated 10/23/09.
Client # 19 was admitted on 8/18/09. The facility failed to document the proposed support services on the treatment plan dated 9/23/09.
Client # 20 was admitted on 3/11/09. The facility failed to document the proposed support services on the treatment plan dated 4/2/09.
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Plan of Correction
Our Clinical Supervisor will conduct an in-house training on individual Treatment Plans. This training will be held on 01/04/10. The Clinical Supervisor will review the Treatment Plans in supervision with each counselor and will continue to do quality reviews on a monthly basis. Clinical Supervisor will monitor for compliance. This will be immediate and on-going. |
709.93(a)(5) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on the review of client records on November 23, 24 and 25, 2009, the facility failed to document a plan or strategy as a component of the progress notes for the subsequent treatment session in 10 of 20 client records reviewed.
The findings included:
Twenty client record were reviewed. The facility failed to include the plan (strategy) in the progress notes in 10 of the 20 client records reviewed.
Client # 2 was admitted on 8/4/09. The facility failed to include a plan component in the individual progress notes.
Client # 9 was admitted on 7/18/09. The facility failed to include a plan component in the individual progress notes.
Client # 10 was admitted on 9/10/08. The facility failed to include a plan component in the individual progress notes.
Client # 11 was admitted on 1/22/09. The facility failed to include a plan component in the individual progress notes.
Client # 12 was admitted on 5/4/09. The facility failed to include a plan component in the individual progress notes.
Client # 15 was admitted on 6/24/09. The facility failed to include a plan component in the individual progress notes.
Client # 16 was admitted on 7/17/09. The facility failed to include a plan component in the individual progress notes.
Client# 17 was admitted on 10/20/09. The facility failed to include a plan component in the individual progress notes.
Client# 19 was admitted on 8/18/09. The facility failed to include a plan component in the individual progress notes.
Client# 20 was admitted on 3/11/09. The facility failed to include a plan component in the individual progress notes.
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Plan of Correction
We addressed the issue of client records (Progress Notes) in a clinical meeting on 12/01/09. Each progress note will now include an individualized plan of action. In addition, the Clinical Supervisor will be reviewing the progress notes in supervision and will increase our quality reviews of this topic in monthly quality reviews. Clinical Supervisor will monitor for compliance. This will be immediate and on-going. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of facility policy and procedure on aftercare planning and an interview with the facility director and client record documentation, the facility failed to document aftercare plans in accordance with the timeframe listed in facility procedure nine of twenty client records.
The findings included:
Twenty client records were reviewed on November 23, 24 and 25, 2009. The written facility policy for completion of aftercare plans required that the plans be completed within 14 days of the admission date. This timeframe was verified by the facility director in an interview on 11/23/09 at approximately 11:30 A.M. Aftercare plans were documented after the 14 day time frame in 9 of 20 client records:
Client # 3 was admitted on 9/6/07. The aftercare plan was not documented until 10/10/07.
Client # 5 was admitted on 8/24/09. There was no documentation of an aftercare plan as of 11/24/09.
Client # 6 was admitted on 6/17/09. The aftercare plan was not documented until 7/21/09.
Client # 7 was admitted on 6/10/09. The aftercare plan was not documented until 7/15/09
Client # 8 was admitted on 6/9/09. The aftercare plan was not documented until 7/27/09.
Client # 9 was admitted on 7/8/09. The aftercare plan was not documented until 8/14/09
Client # 10 was admitted on 9/10/08. The aftercare plan was not documented until 10/6/08.
Client # 13 was admitted on 12/3/08. The aftercare plan was not documented until 1/16/09.
Client # 14 was admitted on 12/18/08. The aftercare plan was not documented until 1/16/09.
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Plan of Correction
All Aftercare Plans will be completed within 14 days, as per Discovery House Policy. Clinical Supervisor will monitor for compliance. This will be immediate and on-going. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on the review of client records, the facility failed to document discharge summaries which included the reasons for treatment and the services offered to the client in four of four closed client records.
The findings included:
Four closed client records were reviewed during the record review portion of the inspection on November 23, 2009. The discharge summaries in four of four client records did not include documentation of the reasons for treatment and the services offered during treatment.
Client # 2 was admitted on 8/4/09 and discharged on 9/22/09. The facility failed to document the reasons for treatment on the discharge summary. It was noted that the listing of services offered to the client did not include individual and group treatment services that were provided to the client during treatment.
Client # 3 was admitted on 9/6/07 and discharged on 11/13/09. The facility failed to document the reasons for treatment on the discharge summary.
Client # 4 was admitted on 5/3/07 and discharged on 5/12//09. The facility failed to document the reasons for treatment on the discharge summary. It was noted that the listing of services offered did not include individual or group treatment services that were provided to the client during treatment.
Client # 5 was admitted on 8/24/09 and discharged on 9/29/09. The facility failed to document the reasons for treatment on the discharge summary. It was noted that the listing of services offered did not include individual or group treatment services that were provided to the client during treatment.
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Plan of Correction
Our Clinical Supervisor conducted an in-house training on Discharge Summaries on 12/01/09. The Clinical Supervisor will review the Discharge Summaries in supervision with each counselor and will continue to do quality reviews of all Discharge Summaries on a monthly basis to ensure compliance with State Regulations. Clinical Supervisor will monitor for compliance. This will be immediate and on-going. |