INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the November 25, 2009 licensure renewal inspection. The follow-up inspection was conducted on April 13, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 May 12, 2010.
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Plan of Correction
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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 inspection of the patient record storage area, the facility failed to secure patient records containing patient identifying information in secured locked storage containers.
The findings include:
The patient record storage area was inspected on April 13, 2010. One patient record was sitting on top of the locked file cabinet. The patient's record was not secured and was in an unlocked and unmonitored area of the building.
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Plan of Correction
The area in question is where we store our discharged charts. These file cabinets will continue to remain locked at all times and all associates will file the charts in these cabinets at all times. This will be immediate and on-going. Program Director will monitor for compliance. |
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 the review of patient records, the facility failed to document a psychosocial evaluation which included a clinical evaluation of the patient's problem/needs, assess and strengths, support systems, coping mechanisms and the counselor's conclusion/impressions in five of seven patient records.
The findings include:
Eleven patient records were reviewed on April 13, 2010. Seven patient records reviewed required psychosocial evaluations. The facility did not document a psychosocial evaluation which included a clinical evaluation of the patient's problem/needs,assess and strengths, support systems,coping mechanisms and/or the counselor's conclusion/impressions in patient records # 1, 2, 3, 5 and 6.
The psychosocial evaluation in client record # 1 did not include a clinical evaluation of the patient's problem/needs, support systems, coping mechanisms and the counselor's conclusion/impressions which identified possible relationships, conditions and causes leading to the client's current situation as of 4/12/10. The client was admitted on 2/12/10 and the psychosocial evaluation was dated 4/12/10.
The psychosocial evaluation in client record # 2 did not include a clinical evaluation of the patient's support systems and coping mechanisms which identified possible relationships, conditions and causes leading to the client's current situation as 4/13/10. The client was admitted on 1/28/10 and the psychosocial evaluation was dated 1/28/10.
The psychosocial evaluation in client record # 3 did not include a clinical evaluation of the patient's problem/needs, assess and strengths, support systems,coping mechanisms and the counselor's conclusion/impressions which identified possible relationships, conditions and causes leading to the client's current situation as 4/13/10. The client was admitted on 2/4/10 and the psychosocial evaluation was dated 2/3/10.
The psychosocial evaluation in client record # 5 did not include a clinical evaluation of the patient's support systems and the counselor's conclusion/impressions which identified possible relationships, conditions and causes leading to the client's current situation as 4/13/10. The client was admitted on 3/16/10 and the psychosocial evaluation was dated 3/15/10.
The psychosocial evaluation in client record # 6 did not include a clinical evaluation of the patient's support systems and the counselor's conclusion/impressions which identified possible relationships, conditions and causes leading to the client's current situation as 4/13/10. The client was admitted on 3/11/10 and the psychosocial evaluation was dated 3/10/10.
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Plan of Correction
We are in the process of developing a new psychosocial evaluation which will automatically include a clinical evaluation of the patient's problem/needs, assess and strengths, support systems, coping mechanisms and/or the counselor's conclusion/impressions of the patient. The evaluation will also include evaluation of the current issues which lead to the client's current situation. The staff will be trained on this new evaluation and Clinical Supervisor will monitor for compliance. The new evaluation will be implimented once it is approved by our corporate office. Prior to its approval, our intake coordinator will include her assessments into each evaluation. This will be immediate and on-going. |
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 an individual treatment and rehabilitation plan which included the type and frequency of treatment and rehabilitation services in three of six patient records.
The findings include:
Eleven patient records were reviewed on April 13, 2010. Six were required to have an individual treatment and rehabilitation plan which included the type and frequency of treatment and rehabilitation services. The facility did not document the type and/or frequency of treatment and rehabilitation services in patient records # 1, 2 and 6.
In patient record # 1, the treatment plan, dated March 29, 2010 did not contain the frequency of treatment and rehabilitation services the patient was to receive.
In patient record # 2, the treatment plan, dated February 9, 2010 did not contain the frequency of treatment and rehabilitation services the patient was to receive.
In patient record # 6, the treatment plan, dated April 7, 2010 did not contain the type or frequency of treatment and rehabilitation services the patient was to receive.
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Plan of Correction
The Clinical Supervisor and Director have been reviewing the treatment plans more thoroughly during supervision and we are showing progress. We will conduct another in-house training on treatment plans on 5/3/10. We will ensure that all counselors include the frequency and type of service in every treatment plan. This will be immediate and on-going. Clinical Supervisor will monitor for compliance.
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