INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16 through April 18, 2012, by staff from the Division of Drug and Alcohol Program Licensure. 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)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's policy and procedures and administrative documentation, the facility failed to document an overall plan to address training needs, as required by regulation.
The findings include:
On April 16, 2012, the facility's policy and procedures were reviewed. Per the agency policy and procedure the overall training plan will be completed by February 10th of each year. The regulation requires an overall plan for addressing training needs to be completed as a component of a staff development program. The facility documented an overall training plan, however, it failed to include projected trainers and dates of training opportunities. The plan only addressed training topics.
The facility director was interviewed on April 16, 2012. The facility director confirmed that an overall plan for addressing training needs did not include dates of training opportunity and potential trainers.
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Plan of Correction
Director and Clinical Supervisor will develop a written plan that provides speakers and dates for 2012 trainings. The document will also record year to date completion information. Clinic staff will have input on speakers and dates for trainings.
Each January the Director and Clinical Supervisor will develop a comprehensive training plan for the year utilizing a staff survey of needs and resources. Staff meetings will be utilized to gather additional plan input. The plan will address overall program training direction and provide details of the planned training topics, speakers and dates. Resources to be utilized will be spelled out. The plan is the responsibility of the Director to complete by February 10 of each year. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the staffing requirements and the facility summary report form completed by the facility on April 16, 2012, the facility failed to ensure that staff to client ratios remained at or under 35:1.
The findings included:
Based on the number of hours the employee worked at this facility and the number of clients at the facility, the overall client to counselor ratio exceeded the maximum ratio of 35:1.
On April 16. 2012, the Staffing Requirements Facility Summary Report form, completed by the facility, was reviewed. The form listed each counselor and counselor assistant's caseload. The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based on the total number of hours per week that the facility reported the employees devoted to their clients (330), divided by the total number of hours in the facility's standard work week (40), equaled (8.75) Full-time Equivalent staff. By dividing the total number of clients (292) by the 8.75 FTE, the facility's overall client to counselor ratio was 36:1.
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Plan of Correction
The Director hired a Counselor on 4/23/2012, bringing the ratio into compliance. A Counselor resigned effective 05/01/2012. A replacement has been selected and will begin employment on 06/04/2012.
The Clinical Supervisor will record the patient to staff ratio on a weekly basis and will report this figure weekly to the Director.
Anticipating future counselor vacancies, the program strategy is to prevent non-compliance by recruiting and hiring a PRN Counselor with training, experience and flexibility to work with immediate notice. Director is responsible.
A pool of candidates resumes for full time permanent work will be maintained. Interviews will be conducted at the first indication of a staff departure so that permanent replacement staff will be hired within one month. Director is responsible.
The expectation will be that current staff give one month notice of resignations and transfers (to another Discovery House facility). This will allow more recruitment time than the current expectation of two weeks notice. Director is responsible for educating staff of this expectation.
The Director is responsible to monitor patient to staff ratio and assure compliance.
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate the female patient bathroom with an exhaust fan or window.
The findings include:
Based on a physical plant inspection with the director on April 17, 2012, the facility did not have a working exhaust fan or window in the female patient bathroom.
The director confirmed the exhaust fan was inoperable during the inspection.
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Plan of Correction
The fan in the female patient bathroom was replaced by Adams Electric on 5/9/2012 and is now in working order.
The Health and Safety Coordinator and Assistant Coordinator will conduct weekly walk through inspections of the facility with a checklist utilized to record any safety, health or regulatory issues. A report will be filed weekly with the Director who will immediately arrange for any needed repairs.
The Director will involve all counseling, medical and administrative staff in continuous monitoring of the facility for safety, health and regulatory issues. Problems will be reported immediately to the Director, or in the Director's absence, to the Clinical Supervisor. Reminders to monitor will be issued at least monthly during staff meetings.
The Director is responsible for assuring that the facility meets all standards. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record log, the facility failed to document eight of twelve monthly fire drills.
The findings include:
The fire drill record log was reviewed on April 16, 2012. The log was reviewed from April 2011 until March 2012. Eight of those twelve months did not document a fire drill was conducted. There were no fire drills documented for the months of April 2011, May 2011, June 2011, July 2011, August 2011, September 2011, October 2011, and November 2011. This finding was confirmed with the facility director on April 16, 2012 and was not disputed.
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Plan of Correction
Director, in cooperation with the staff Health and Safety Coordinator, has developed a written plan for monthly fire drills. The Health and Safety coordinator, with back up by an assistant, will implement the plan. The plan includes the date each month the drill will be held. The drill date will not be announced ahead of time to staff. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based upon the review of the fire drill records, the facility failed to conduct fire drills during different times of the day and on different shifts in three for four fire drills reviewed.
The findings include:
The fire drill record was reviewed on April 16, 2012. Three of the four fire drills were documented between the hours of 10:15 a.m. and 11:30 a.m. The clinic hours of operation are from 5:00 a.m. until 1:30 p.m. The facility failed to conduct drills at different times of the day and on different staffing shifts, as required.
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Plan of Correction
The Director, in cooperation with the staff Health and Safety Coordinator, has developed a written plan for monthly fire drills. The Health and Safety coordinator, with back up by an assistant, will implement the plan. The plan rotates the days of the week and the times of day the drills will be held. Early dosing hours and weekend days are included. The drill day and time will not be announced ahead of time to staff. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs, the facility failed to activate a fire alarm or smoke detector in two of four fire drills.
The findings include:
The fire drill logs were reviewed on April 16, 2012. Per regulation, the nonresidential facility shall set off a fire alarm or smoke detector during each fire drill. The fire drill log was reviewed for documentation of fire drills from the time period of April 2011 to March 2012. The facility only conducted four fire drills during this time frame. The facility failed to document on the fire drill logs that a smoke detector or fire alarm had been activated for the fire drills documented on February 28, 2012 and March 26, 2012.
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Plan of Correction
The facility fire drill log was revised by the Director on 5/9/2012 to include a yes/no check box section indicating whether or not a fire alarm was activated for the drill.
The Blair office Health and Safety Coordinator or Assistant Coordinator will conduct the monthly fire drills and complete the fire drill log.
The director reviews and signs off on each log, assuring completion. Feedback will be provided by the Director to all staff regarding fire drill results and needed process changes to improve the results. Staff meeting discussion will occur monthly with review of significant findings from the log, including evacuation time, areas of the building not checked and other improvement needs arising from the drill.
The Director will be responsible to monitor. |
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 the review of patient records, the facility failed to ensure that the narcotic treatment physician determined the patient's dose and schedule.
The findings include:
Nineteen patient records were reviewed on April 17 through April 18, 2012. One patient record was reviewed for documentation for an involuntary termination decision. Patient record # 11 was admitted into treatment on May 17, 2010 and was discharged on November 25, 2011. The patient received and signed the administrative withdrawal notification for non-compliance on November 15, 2011 at 7:16 a.m. In the notification letter the patient was informed that her dose would be decreased by 18 mgs per day until November 25, 2011. The notification was signed by the patient, a counselor, the clinical supervisor, and the facility director. There was no documentation in the record that indicated that the narcotic treatment physician was involved in the decision to terminate the patient's treatment and determine the patient's decrease in her dose. Further review of the record indicated that the narcotic treatment physician did document a dose change order on November 15, 2011 at 9:48 p.m. This order was documented after the decision to terminate the patient was written and signed by the client, counselor, clinical supervisor, and facility director. The order the doctor wrote was identical to the wording on the administrative withdrawal notification.
An interview with the clinical supervisor on April 17, 2012 at 3:15 p.m. confirmed this finding.
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Plan of Correction
The Physician will determine that an MSW will begin and will document in the record that an MDT was held and that he/she decided to initiate the MSW. Following the 24 hour notice period to the patient, the Physician will write the order to taper the patient.
The Clinical Supervisor will review MSW documentation to ensure accuracy when an MSW is in order.
On 6/1/2012 there will be training of the physician, Clinical Supervisor and Nurse Supervisor. On 5/31/2012 training was held for all staff regarding this process.
The Physician is responsible for compliance with this process.
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709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on the review of patient records, the facility failed to document a physical examination that included a general appearance that was unique to the patient in 15 of 15 records reviewed.
The findings include:
Nineteen patient records were reviewed on August 17 and August 18, 2012. Fifteen patient records were reviewed for initial physical examinations that must include documentation of the patient's general appearance. Patient records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 14, 15, 16, 17, 18, and 19 all had identical general appearances. Every documentation of a physical examination contained the following statement documented for the patient's general appearance, "alert and well oriented, normal speech pattern and gait."
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Plan of Correction
Citation has been reviewed with staff to assure that auto-population of data in the initial physical examination form is not used. Individualized data for each patient is to be entered. The Director and Clinical Supervisor will audit 100% of new admission physicals from April 18 to June 15. Ten annual physicals will be audited during the same period to assure individualized data entry. Results of audits will be reviewed with the Physician and Physician's Assistant. |