INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 21-23, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection,Discovery House Ha 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 January 15, 2010.
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Plan of Correction
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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 the review of employee records and an interview with the facility director, the facility failed to document the required mandatory disease training for all clinical staff within one year of the date of hire in one of six employee records.
The findings included:
The records of eight clinical staff were reviewed during the annual licensing inspection . Six staff in the sample were required to have the mandatory communicable disease training completed as they had more than one year of employment documented. Two clinical staff had less than one year of employment in clinical positions.
Employee # 9 was hired on 12/22/2008. There was no documentation of the mandatory communicable disease training as of 12/21/09. In an interview with the facility director on 12/ 21/09 he acknowledged that this employee did not have the training and was scheduled to receive it on January 13, 2010.
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Plan of Correction
Associate in question has been scheduled to attend the mandatory Communicable Disease Training on 1/13/10. Effective Immediately the Program Director will review training hours and plans on a quarterly basis to ensure required trainings have been obtained. Program Director with the assistance of the CRNP will conduct this training on a yearly basis to ensure future compliance. Program Director will monitor for compliance. |
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 the review of facility financial documents during the onsite licensing inspection , the facility failed to document an audit for the year ended 12/31/2008.
The findings included:
Division staff reviewed the documentation presented when the annual audit was requested. The documentation presented by the facility director consisted of a financial statement for the year ended 12/31/08. The letter from the accountant stated"...we have not audited or reviewed the accompanying financial statements and do not express an opinion or any other form of assurance on them." There is a statement of income and expenses and balances. The documentation presented failed to meet the requirement for the annual financial audit.
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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 |
709.28(c) 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:
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Observations
Based on the review of client records during the annual licensing inspection and interviews with facility staff, the facility failed to ensure that informed and voluntary consents were completed prior to each disclosure of information contained in the client records.
The findings included:
Twenty three client records were reviewed during the annual licensing inspection. Each record was required to have a signed consent for each disclosure of information from each client record. Specific findings are as follows:
Documentation in client record # 3 demonstrated that the facility released information to two separate third party payers without obtaining a written consent to release information from the client. The client was admitted on 12/18/09.
Documentation in client record # 4 demonstrated that the facility released information to a third party payer without obtaining a written consent to release information from the client. The client was admitted on 6/4/09.
Documentation in client record # 5 demonstrated that the facility released information to a family member without obtaining a written consent to release information from the client. The client was admitted on 9/10/09.
Documentation in client record # 6 demonstrated that the facility released information to a third party payer without obtaining a written consent to release information from the client. The client was admitted on 1/7/09.
Documentation in client record # 7 demonstrated that the facility released information to two separate third party payers without obtaining a written consent to release information from the client. The client was admitted on 11/25/09.
Documentation in client record # 8 demonstrated that the facility released information to a third party payer without obtaining a written consent to release information from the client. The client was admitted on 5/12/09.
Documentation in client record # 11 demonstrated that the facility released information to two separate third party payers without obtaining a written consent to release information from the client. The client was admitted on 11/23/09.
Documentation in client record # 12 demonstrated that the facility released information to two separate third party payers without obtaining a written consent to release information from the client. The client was admitted on 10/26/09.
Documentation in client record # 13 demonstrated that the facility released information to two separate third party payers without obtaining a written consent to release information from the client. The client was admitted on 4/6/09.
Documentation in client record # 14 demonstrated that the facility released information to two separate third party payers without obtaining a written consent to release information from the client. The client was admitted on 8/20/09.
Documentation in client record # 15 demonstrated that the facility released information to a third party payer without obtaining a written consent to release information from the client. The client was admitted on 11/12/08.
Documentation in client record # 16 demonstrated that the facility released information to a third party payer without obtaining a written consent to release information from the client. The client was admitted on 2/24/09.
Documentation in client record # 18 demonstrated that the facility released information to a third party payer without obtaining a written consent to release information from the client. The client was admitted on 6/16/09.
Documentation in client record # 22 demonstrated that the facility released information to a third party payer without obtaining a written consent to release information from the client. The client was admitted on 1/28/09.
During the inspection the ongoing discussions about this issue were held on December 21, 22 and 23. Notes were placed on each client record in which this deficiency was found . The facility director acknowledged that this was a problem and that staff would work to rectify the issue promptly.
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Plan of Correction
The Program Director and Clinical Supervisor will conduct a training to ensure there is a separate release completed for each patient's managed care contractor, for the Dept. Of Public Welfare. The Clinical Supervisor will monitor each patient record through admission chart audits to ensure there is a release in place. The Program Director and Lead Counselor will do sporadic checks to monitor compliance. This will take place within 30 days. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on the review of client records and the facility policy regarding the preliminary treatment plan and ongoing dialogues/interviews with the facility director , the facility failed to document preliminary treatment plans in accordance with written facility policy and procedure in 18 of 23 client records.
The findings included:
Twenty three client records were reviewed during the annual inspection . Each was required to have a preliminary treatment plan documented on the first day of treatment, as required by facility policy. The facility director was interviewed at 8:00 AM on 12/21/09 and acknowledged that this timeframe as stated in agency policy was correct. As the issue of late preliminary treatment plans was noted in the client record reviews on 12/21/09 and 12/22/09, discussions were held with the facility director about the timeframes stated in facility policy were not followed. The facility director reviewed the findings and agreed that this was an accurate observation. Specific findings are as follows:
Client # 2 was admitted on 8/19/09. A preliminary treatment plan was not documented as of 12/21/09.
Client # 3 was admitted on 12/18/08. The preliminary treatment plan was not document until 1/6/09.
Client # 4 was admitted on 6/4/09. A preliminary treatment plan was not documented as of 12/21/09.
Client # 5 was admitted on 9/10/09. The preliminary treatment plan was not document until 9/16/09.
Client # 6 was admitted on 1/7/09. The preliminary treatment plan was not document until 1/9/09.
Client # 8 was admitted on 5/12/09. The preliminary treatment plan was not document until 5/26/09.
Client # 9 was admitted on 6/11/09. The preliminary treatment plan was not document until 6/24/09.
Client # 10 was admitted on 6/16/09. The preliminary treatment plan was not document until 6/18/09.
Client # 11 was admitted on 11/23/09.The preliminary treatment plan was not document until 11/30/09.
Client # 12 was admitted on 10/26/09.The preliminary treatment plan was not document until 11/5/09.
Client # 13 was admitted on 4/6/09. The preliminary treatment plan was not document until 4/8/09.
Client # 15 was admitted on 11/12/08.The preliminary treatment plan was not document until 11/14/08.
Client # 18 was admitted on 6/16/09. The preliminary treatment plan was not document until 6/23/09.
Client # 19 was admitted on 1/22/09.The preliminary treatment plan was not document until 1/29/09.
Client # 20 was admitted on 11/25/09.The preliminary treatment plan was not document until 12/3/09.
Client # 21 was admitted on 7/16/09. The preliminary treatment plan was not document until 7/20/09
Client # 22 was admitted on 1/28/09.The preliminary treatment plan was not document until 2/9/09
Client # 23 was admitted on 10/9/09. The preliminary treatment plan was not document until 10/13/09.
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Plan of Correction
The Program Director and Clinical Supervisor will conduct a training on preliminary treatment plans and time frames when they are to be completed. Clinical Supervisor and Lead counselor will review weekly to ensure preliminary treatment plans are started on day one and completed as policy indicates. Program Director will also conduct chart reviews on a quarterly basis to ensure compliance. This will take place within 30 days |
709.92(a) 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:
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Observations
Based on a review of client records during the annual licensing inspection, the facility failed to ensure that each client had documentation of an individualized treatment plan appropriate to the client's treatment needs.
The findings included:
Twenty three client records were reviewed during the annual licensing inspection. each was required to have documentation of an individualized treatment plan. Treatment plans reviewed were not individualized, but were standardized. Goals and objectives documented on the treatment plans reviewed were similar or identical in the client records reviewed. The treatment plans addressed coping skills, identifying triggers, dosing daily and meeting financial requirements in each client record reviewed. The facility failure to provide for individualized treatment plans was evident in client records # 1, 2, 3, 5, 6, 7, 9, 10, 11, 12, 14, 15, 19, 20, 21 and 22.
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Plan of Correction
The Program Director and Clinical Supervisor will conduct a training on treatment planning, training will include identifying client needs and development of an individualized treatment plan, and documentation of the type and frequency of service that will be provided for the patient.. The Clinical Supervisor and lead counselor will also address this individually in supervision to ensure compliance by each counselor. The Clinical Supervisor and lead counselor will monitor prior to approval of the treatment plan. The Program Director will also monitor quarterly to ensure compliance. This will take place within 30 days. |
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 proposed type of support services on each treatment plan in 11 of 22 client records.
The findings included:
Twenty three client records were reviewed during the annual licensing inspection . Twenty two client records were required to document individualized treatment plans which included the proposed type of support services for the client while in treatment. The proposed support services were not documented on the treatment plans in client records # 1, 2, 3, 4, 6, 7, 9, 16, 19, 21 and 22.
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Plan of Correction
The Program Director and Clinical Supervisor will conduct a training on treatment planning, training will include documenting the type of proposed support services to be provided for each patient. The Clinical Supervisor will also address this individually in supervision to ensure compliance by he counselor. The Clinical Supervisor will monitor prior to approval of the treatment plan. The Program Director will do sporadic checks to ensure compliance. |
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 the facility policy on aftercare plans and client records, and ongoing dialogues and interviews with the facility director throughout the licensing inspection, the facility failed to document aftercare plans within the timeframes specified in facility policy and procedure in 17 of 22 client records.
The findings included:
Twenty three client records were reviewed during the licensing inspection. Twenty two were required to have aftercare plans documented within 14 days of admission as required by facility policy and procedure.
Client # 5 was admitted on 9/10/09. The aftercare plan was not documented until 11/20/09.
Client # 7 was admitted on 11/25/09.The aftercare plan was not documented until 12/21/09.
Client # 8 was admitted on 5/12/09. The aftercare plan was not documented until 6/23/09.
Client # 9 was admitted on 6/11/09. The aftercare plan was not documented until 7/14/09.
Client # 10 was admitted on 6/16/09.The aftercare plan was not documented until 7/16/09.
Client # 11 was admitted on 11/23/09.The aftercare plan was not documented until 12/10/09.
Client # 12 was admitted on 10/26/09.The aftercare plan was not documented until 12/22/09.
Client # 13 was admitted on 4/6/09. The aftercare plan was not documented until 5/4/09.
Client # 14 was admitted on 8/20/09.The aftercare plan was not documented until 9/16/09.
Client # 16 was admitted on 2/26/09. The aftercare plan was not documented until 3/30/09.
Client # 17 was admitted on 1/27/09.There was no documentation of an aftercare plan as of 12/23/09.
Client # 18 was admitted on 6/16/09.The aftercare plan was not documented until 7/15/09.
Client # 19 was admitted on 1/22/09.The aftercare plan was not documented until 2/25/09.
Client # 20 was admitted on 11/25/09.The aftercare plan was not documented until 12/18/09.
Client # 21 was admitted on 7/16/09.The aftercare plan was not documented until 8/17/09.
Client # 22 was admitted on 1/28/09.The aftercare plan was not documented until 2/26/09.
Client # 23 was admitted on 10/9/09.The aftercare plan was not documented until 11/12/09.
Discussions/interviews were held with the facility director on 12/21/09, 12/22/09 and 12/23/09 to discuss the findings that the facility was not adhering to the timeframes required in facility policy and procedure. The facility director confirmed that the aftercare plans were not being completed in the timeframes required.
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Plan of Correction
The Program Director and Clinical Supervisor will conduct a training to ensure that aftercare plans are completed within the time frame specified in the written facility policy. All initial aftercare plans are now being completed at intake to ensure compliance in this area. The Clinical Supervisor will also address this individually in supervision to ensure compliance by the counselor. The Clinical Supervisor will monitor compliance through the admission chart audit. The Program Director will do sporadic checks to ensure compliance. |
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 during the annual licensing inspection, the facility failed to document discharge summaries which included the reasons the client came into treatment and the services offered to each client in five of five client records.
The findings included:
Five closed client records were reviewed during the annual licensing inspection. Each was required to document a discharge summary which included the reasons the client came into the facility for this treatment episode and the specific services provided to the client during the treatment episode.
Client # 1 was admitted on 9/21/09 and discharged on 12/1/09. The discharge summary did not include the reasons for treatment and did not document that the client received individual & group treatment services.
Client # 2 was admitted on 8/19/09 and discharged on 9/4/09.The discharge summary did not include the reasons for treatment and did not document that the client received individual & group treatment services.
Client # 3 was admitted on 12/18/09 and discharged on 11/12/09. The discharge summary did not include the reasons for treatment and did not document that the client received individual & group treatment services.
Client # 4 was admitted on 6/4/09 and discharged on 9/23/09.The discharge summary did not include the reasons for treatment and did not document that the client received individual & group treatment services.
Client # 5 was admitted on 9/10/09 and discharged on 11/6/09. The discharge summary did not include the reasons for treatment and did not document that the client received individual & group treatment services.
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Plan of Correction
The Program Director and Clinical Supervisor will conduct a training on writing discharge summaries, specifically that they must include the reason for treatment and the services provided to the patient during treatment. Clinical Supervisor will also address this individually in supervision to ensure compliance by the counselor. The Clinical Supervisor and program director will also conduct sporadic audits to ensure compliance. |