INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted on February 4-6, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Discovery House 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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records on February 4-6, 2020, the facility failed to collect feedback on completed trainings in employees # 2, 3, 4, 5 and 7.
Employee #2 was hired as the facility director on April 3, 2017 and was still in that position at the time of the inspection.
Employee #3 was hired on March 18, 2013 and promoted to position of clinical supervisor on February 1, 2016 and was still in that position at the time of the inspection.
Employee #4 was hired as a counselor on June 4, 2012 and was still in that position at the time of the inspection.
Employee #5 was hired as a counselor on October 15, 2013 and was still in that position at the time of the inspection.
Employee #7 was hired as a counselor on May 30, 2017 and was still in that position at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The DHBC staff will complete the "Staff Review of Training Form" for each completed training. The issue will be addressed at the staff meeting in April 2020. This will be monitored by the clinical supervisor and the clinic director through monthly training audits. |
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
Based on a review of personnel records and the facility ' s Staffing Requirement Facility Summary Report (SRFSR) on February 4-6, 2020, the facility failed to ensure that employee #7 received at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #7 was hired as a counselor on May 30, 2017 and was due to have the communicable disease training no later than May 30, 2018. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process. This is a repeat citation from the December 20, 2018 inspection.
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Plan of Correction
By March 31, 2020 staff # 7 will have TB/STD training. This will be provided onsite by using the Department of Health Curriculum. This issue will be addressed at the staff meeting in April 2020 and it will be stressed to staff that they receive the appropriate mandatory trainings. This will be monitored by the clinical supervisor and the clinic director through monthly training audits.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the policy and procedures manual on February 4-6, 2020, the facility failed to show documentation of the project director annually updating and signing the manual. The last documentation was dated January 18, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Comprehensive Treatment Center (CTC) Group President, Kim Sanderson signed the Policy and Procedure Manual on February 5, 2020 it is now in the policy and procedure manual |
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 the review of client records on February 4-6, 2020, the facility failed to document completed informed and voluntary consent to release information forms prior to the disclosure of information in client record #9. The consent form was missing what specific information could be disclosed.
Client #9 was admitted on August 2, 2019 and was 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
The clinical supervisor and the clinic director will instruct the staff of the proper procedure to complete the informed and voluntary consent forms contained in the client record, specifically what information can be disclosed. This issue will be addressed at the staff meeting in April 2020. Client#9 will sign the revised form by April 15, 2020. This will be monitored by the clinical supervisor during the monthly records review.
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on the review of client records on February 4-6, 2020, the facility failed to document completed informed and voluntary consent to release information forms prior to the disclosure of information in client record # ' s 1, 2, and 7. The consent forms were missing an expiration date.
Client #1 was admitted on September 5, 2019 and was still active at the time of the inspection.
Client #2 was admitted on June 21, 2019 and discharged on October 14, 2019.
Client #7 was admitted on May 28, 2019 and was 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
The clinical supervisor and the clinic director will instruct the staff of the proper procedure to complete the informed and voluntary consent forms contained in the client record, specifically including an expiration date. This issue will be addressed at the staff meeting in April 2020. Clients #1 and 7 will sign the revised forms by April 15, 2020. This will be monitored by the clinical supervisor during the monthly records review. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records on February 4-6, 2020, the facility failed to ensure there was appropriate documentation of written acknowledgement by the client that the client had been made aware of all of their rights in client record # ' s 1, 2, 7, 9, 10, 11, 13, and 14. The client rights, both the electronic signed version and the handbook, were missing that the facility may temporarily remove portions of the record prior to the inspection by the client and document reasons for removing information.
Client #1 was admitted on September 5, 2019 and was still active at the time of the inspection.
Client #2 was admitted on June 21, 2019 and discharged on October 14, 2019.
Client #7 was admitted on May 28, 2019 and was still active at the time of the inspection.
Client #9 was admitted on August 2, 2019 and was still active at the time of the inspection.
Client #10 was admitted on June 12, 2019 and was still active at the time of the inspection.
Client #11 was admitted on March 11, 2019 and was still active at the time of the inspection.
Client #13 was admitted into the narcotic treatment program methadone maintenance level of service on August 1, 2019 and was still active at the time of the inspection.
Client #14 was admitted on April 23, 2019 and discharged on November 25, 2019.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 20, 2018 inspection.
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Plan of Correction
Clinical Services department will revise the Clients Rights policy and procedure and the patient handbook into conformance with the regulations. Affected clients will sign the revised forms by April 15, 2020. Project management will review policy and procedure revisions with all staff at the April staff meeting.
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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 the physician timesheets for the months of September, October, November and December 2019 on February 4-6, 2020, the facility failed to provide at least one hour of physician time a week, on site, for every ten patients.
During the week of September 15-21, 2019, the patient census was 314. The facility was required to provide at least 31.4 physician hours. There were 12 physician hours documented.
During the week of October 27-November 1, 2019, the patient census was 312. The facility was required to provide at least 31.2 physician hours. There were 26.5 physician hours documented.
During the week of November 17-23, 2019, the patient census was 309. The facility was required to provide at least 30.9 physician hours. There were 20.5 physician hours documented.
During the week of December 15-21, 2019, the patient census was 303. The facility was required to provide at least 30.3 physician hours. There were 24.5 physician hours documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The physician will provide the required on-site hours. The physician is responsible for providing 1/3 of the required hours and the physician assistant is responsible for providing the remaining 2/3 of the required hours. This will be reviewed at the April staff meeting. The clinic director is responsible for monitoring and approving the hours spent on-site by the physician assistant this will be implemented immediately and monitored on an on-going basis. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of client records on February 4-6, 2020, the facility failed to include all required information on the methadone patient consent form in client records #1 and 7. The patient consent form did not include that methadone is transmitted to the unborn child and will cause physical dependence.
Client #1 was admitted on September 5, 2019 and was still active at the time of the inspection.
Client #7 was admitted on May 28, 2019 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Risk during pregnancy. Knowledge of the effects of methadone on the pregnant women and their unborn child is presently inadequate to guarantee that methadone may not produce significant serious side effects.
Methadone is transmitted to the unborn child and may cause physical dependence. The newborn may show irritability and other ill effects from the use of methadone for a brief time following birth. This may require medical intervention.
Abrupt withdrawal from methadone may adversely affect the unborn child which could result in fetal death and/or premature labor.
The use of other drugs in addition to methadone may harm the patient and/or unborn child.
Currently research shows that mothers maintained on methadone can safely breastfeed, unless they are HIV positive, or are known to have another disease or infection where breastfeeding is contraindicated. Hepatitis C is not considered a contraindication for breastfeeding.
Methadone is transmitted to the unborn child and may cause physical dependence. The newborn may show irritability and other ill effects from the use of methadone for a brief time following birth. This may require medical intervention.
This has been added to the informed consent to address the citation. This will be added into the EMR by 4/15/2020 at that time we will have the patients listed above sign the new form.
The clinic director will monitor to check the implementation into the EMR.
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715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of client records on February 4-6, 2020, the facility failed to document dosage level reviews at least twice a year in client record # ' s 3, 7, and 8.
Client #3 was admitted on May 6, 2014 and was still active at the time of the inspection. The last dose review was completed by the physician on November 5, 2018. The client had no documented dose reviews since that date.
Client #7 was admitted on May 28, 2019 and was still active at the time of the inspection. There were no documented dose reviews by the physician since admission.
Client #8 was admitted on September 16, 2014 and was still active at the time of the inspection. The last dose review was completed by the physician on October 18, 2018. The client had no documented dose reviews since that date.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 20, 2018 inspection.
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Plan of Correction
The medical director or physician on staff will conduct all medication dosage reviews, the reviews will be done at least twice a year with each review occurring at least two (2) months apart to determine a patients' therapeutic dosage. This will be addressed at the staff meeting in April 2020. The medical director will be responsible for monitoring patient records on a monthly basis. |
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 client records on February 4-6, 2020, the facility failed to provide patients # ' s 1, 9, 10, 11, 12 and 14 with an average of 2.5 hours of psychotherapy per month during the patient ' s first two years of treatment.
Client #1 was admitted on September 5, 2019 and was still active at the time of the inspection. For the time period of November 2019 through January 2020, the client received a total of 6.5 hours of psychotherapy, which averages to 2.1 hours per month.
Client #9 was admitted on August 2, 2019 and was still active at the time of the inspection. For the time period of November 2019 through January 2020, the client received a total of 4 hours of psychotherapy, which averages to 1.3 hours per month.
Client #10 was admitted on June 12, 2019 and was still active at the time of the inspection. For the time period of November 2019 through January 2020, the client received a total of 1 hour of psychotherapy, which averages to .3 hours per month.
Client #11 was admitted on March 11, 2019 and was still active at the time of the inspection. For the time period of November 2019 through January 2020, the client received a total of 2.5 hours of psychotherapy, which averages to .8 hours per month.
Client #12 was admitted on September 20, 2017 and discharged on September 26, 2019. For the time period of June through August 2019, the client received a total of 5.5 hours of psychotherapy, which averages to 1.8 hours per month.
Client #14 was admitted on April 23, 2019 and discharged on November 25, 2019. For the time period of August through October 2019, the client received a total of two hours of psychotherapy, which averages to .6 hours per month.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All patients for the first two years will do the required 2.5 hours of counseling per month. Counselors will make every effort to have the counseling completed each month. If the patient does not show a no-show note will be placed in the EMR to show attempts to get the required hours. This will be addressed in the April staff meeting. This will be monitored by the clinical supervisor and program director.
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715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of client records on February 4-6, 2020, the facility failed to include documentation of an initial intake physical examination in client record # 7.
Client #7 was admitted on May 28, 2019 and was 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
The physician/physician assistant shall document in the patient's record the results of the initial physical exam. The physician/physician assistant will sign the appropriate forms at the time of the patient's initial physical exam. This will be addressed in the April staff meeting. The clinic director will be responsible for monitoring the patient record to verify it is signed in a timely manner.
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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 client records on February 4-6, 2020, the facility failed to document an annual physical reevaluation by the narcotic treatment physician in client record # ' s 3, 6 and 8.
Client #3 was admitted on May 6, 2014 and was still active at the time of the inspection. The most recent physical examination was on November 5, 2018 with a reevaluation due no later than November 5, 2019; however, it was not documented as of the date of the inspection.
Client #6 was admitted on August 20, 2010 and was still active at the time of the inspection. The most recent physical examination was on October 23, 2018 with a reevaluation due no later than October 23, 2019; however, it was not documented as of the date of the inspection.
Client #8 was admitted on September 16, 2014 and was still active at the time of the inspection. The most recent physical examination was on November 30, 2018 with a reevaluation due no later than November 30, 2019; however, it was not documented as of the date of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The physician or physician assistant is responsible for completing the patient's annual physical. The physician or physician assistant will complete the annual physical exam including the full documentation of a re-evaluation on the patient on a timely basis. The clinic director is responsible for compliance with the standard. Implementation will begin immediately and reviewed on an on-going basis. |
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 client records on February 4-6, 2020, the facility failed to document a completed annual clinical evaluation in client record # ' s 6 and 8.
Client #6 was admitted on August 20, 2010 and was still active at the time of the inspection. The most recent annual clinical evaluation was completed on August 30, 2019; however, it was missing the required dated medical director's signature.
Client #8 was admitted on September 16, 2014 and was still active at the time of the inspection. The most recent annual clinical evaluation was completed on September 16, 2019; however, it was missing the required dated medical director ' s signature.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
DHBC counselors will perform an annual evaluation of each patient, the review will be documented in the patients' medical record. The medical director will review date and sign the evaluation. This issue will be addressed at the staff meeting in April 2020. This will be monitored by the clinical supervisor during the monthly records review
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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 client records on February 4-6, 2020, the facility failed to document treatment plan updates within the regulatory timeframe in client # ' s 1, 3, 11, 14 and 15.
Client #1 was admitted on September 5, 2019 and was still active at the time of the inspection. A treatment plan was completed on September 5, 2019 and the next update was due no later than November 5, 2019; however, the next update was completed on December 6, 2019.
Client #3 was admitted on May 6, 2014 and was still active at the time of the inspection. A treatment plan update was completed on August 30, 2019 with the next update due no later than October 30, 2019; however, the next update was completed on November 20, 2019.
Client #11 was admitted on March 11, 2019 and was still active at the time of the inspection. A treatment plan update was completed on September 13, 2019 with the next update due no later than November 13, 2019; however, the next update was completed on January 3, 2020.
Client #14 was admitted on April 23, 2019 and discharged on November 25, 2019. A treatment plan update was completed on August 12, 2019 with the next update due no later than October 12, 2019; however, the next update was completed on October 30, 2019.
Client #15 was admitted on April 4, 2018 and discharged on August 20, 2019. A treatment plan update was completed on June 3, 2019 with the next update due no later than August 3, 2019; however, the next update was completed on August 12, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
DHBC counselors will review and update patient's treatment plans on a regular basis but at least every sixty (60) days, the review will be documented in the patients' medical record. This issue will be addressed at the staff meeting in April 2020. This will be monitored by the clinical supervisor during the monthly records review. |
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 client records on February 4-6, 2020, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in client record # ' s 1, 2, 6, 8, 9, 10, 11, 12, 13 and 14.
Client #1 was admitted on September 5, 2019 and was still active at the time of the inspection. The treatment plan dated September 5, 2019 indicated one hour of individual and 1.5 hours of group sessions weekly. The record of service and progress notes indicated that the client did not receive any individual sessions between November 14 - December 17 and zero sessions after December 19, 2019. The client did not receive any group sessions between November 14 - December 10, 2019 and December 12, 2019 - January 22, 2020.
Client #2 was admitted on June 21, 2019 and was discharged on October 14, 2019. The treatment plan dated June 21, 2019 indicated one hour of individual and 1.5 hours of group sessions weekly. The record of service and progress notes indicated that the client was a no-show on July 5, 2019 and did not list any attended group or individual sessions or missed appointments for the duration of his/her admission.
Client #6 was admitted on August 20, 2010 and was still active at the time of the inspection. The treatment plan, dated August 15, 2019, indicated one hour of group or individual sessions every other month. The record of service and progress notes indicated the client received zero therapy hours during the months of October 2019 through January 2020.
Client #8 was admitted on September 16, 2014 and was still active at the time of the inspection. The treatment plan dated September 18, 2019 stated one hour of group or individual therapy every other month. The record of service and progress notes indicated that the client received two half hour individual sessions on September 18, 2019 and November 20, 2019. There were no sessions during the months of October 2019, December 2019 and January 2020.
Client #9 was admitted on August 2, 2019 and was still active at the time of the inspection. The treatment plan dated August 30, 2019 indicated one hour of individual and 1.5 hours of either group or individual sessions each month. The record of service and progress notes indicated that the client received during the month of November 2019, one hour of individual therapy and zero group sessions. In December 2019, the client received no therapy. In January 2020, the client received two hours of individual therapy and zero hours of group sessions.
Client #10 was admitted on June 12, 2019 and was still active at the time of the inspection. The treatment plan dated July 19, 2019 indicated 2.5 hours of therapy a month with one of those hours being in individual sessions. The record of service and progress notes indicated that the client received zero therapy hours in October 2019, November 2019 and January 2020. The client received one hour of individual therapy in December 2019 and zero hours of group therapy.
Client #11 was admitted on March 11, 2019 and was still active at the time of the inspection. The treatment plan dated May 3, 2019 indicated 2.5 hours of therapy per month. The record of service and progress notes indicated that the client received 1.5 hours of group therapy and zero hours of individual sessions in October 2019. The received zero hours of therapy hours in November 2019. In December 2019, the client received one hour of individual therapy and zero hours of group sessions. In January 2020, the client received 1.5 hours of group sessions and zero hours of individual therapy.
Client #12 was admitted on September 20, 2017 and discharged on September 26, 2019. The treatment plan dated July 30, 2019 indicated 2.5 hours of therapy per month. The record of service and progress notes indicated that the client received one individual hour of therapy and zero group sessions in July 2019. In August 2019, the client received two hours of individual therapy and zero hours of group sessions.
Client #13 was admitted on October 15, 2015 and discharged from the suboxone program on August 1, 2019. The treatment plan dated April 19, 2019 individual one hour of individual therapy per month. The record of service and progress notes indicated the client received zero therapy hours in June 2019.
Client #14 was admitted on April 23, 2019 and discharged on November 25, 2019. The treatment plan dated May 22, 2019 indicated 2.5 hours per month of therapy. The client received on hour of individual therapy and zero hours of group therapy during the months of August and September 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
DHBC counselors will continually review the individual patient's treatment and rehabilitation plan and provide treatment based on the individuals plan on file in the patient record. This issue will be addressed at the staff meeting in April 2020. This will be reviewed and monitored by the clinical supervisor during the monthly records review.
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