INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 15 through March 17, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House, Inc. 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 April 23, 2011.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel records the facility failed to ensure that a training plan was developed annually with input from both the employee and the supervisor.
The findings include:
Thirteen personnel records were reviewed on March 15, 2011. Ten records required individual training plans. Nine out of ten personnel records, specifically records # 2, 3, 4, 5, 6, 7, 8, 12, and 13 had training plans. However, they failed to include authentication by the staff and their supervisor to allow the inspector to determine whether or not they were developed by the employee and their supervisor. An interview with the facility director and clinical supervisor on March 15, 2011 confirmed this finding.
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Plan of Correction
The 2011 Staff Training Plan with input from both the staff member and supervisor was developed. The new plan includes authentication by the staff member and their supervisor. The Director will ensure input is included annually and authentication is completed.
Completed on 3/18/11 |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant tour on March 16, 2011, the program manager's office included a heater that was not permanently mounted or installed.
The findings include:
The program manager's office included a heater that was not permanently mounted or installed. The facility director and program manager confirmed this finding. The problem was immediately corrected and the heater was removed from the facility.
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Plan of Correction
The Safety Team will ensure that no heaters, that are not permanently mounted or installed, are in the clinic.
The Safety Team Leader is responsible for ensuring that no portable heaters are on the premises. The target date for comletion is 3/17/2011.
The Director will ensure ongoing compliance.
The heater was removed from the clinic on 3/17/2011. |
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 interview with facility staff, the facility failed to document an annual audit of financial activities for the year that ended December 31, 2009.
The findings included:
During the onsite licensing inspection conducted from March 15 through 17, 2011, 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 letter from the accountant stated "...A review consists principally of inquiries of group personnel and analytical procedures applied to financial data. It is substantially less in scope than an audit in accordance with auditing standards generally accepted in the United States of America, the objective of which is the expression of an opinion regarding the consolidated financial statements taken as a whole. Accordingly we do not express such an opinion."
The documentation presented failed to meet the requirement for the annual financial audit.
Facility staff were interviewed regarding the documentation and content of the annual audit and confirmed that this was the only fiscal document available for review.
This is a repeat citation from the licensing inspection conducted on April 13 through 15, 2010. The plan of correction for the April 13 through 15, 2010 inspection stated, "Discovery House will conduct an audit for FY 2010. We will submit a 2009 compellation review and an engagement letter for 2010. The director will be responsible to ensure that this is completed."
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Plan of Correction
Discovery House has conducted an audit for FY 2010. The compellation review and an engagement letter have been sent verifying the completion of this financial audit of fiscal activities for the year. The audit documentation will be sent to the Department of Health division of program licensure upon completion from the external accountant once possessed by Discovery House. This financial audit documentation will meet the acceptable auditing standards requested and will be addressed/completed according to the state requirements. The responsible parties for this correction will be the Program Sponsor and the Program Director.
Furthermore, the Program Sponsor and Program Director will take the necessary steps to ensure that the financial audit of fiscal activities is completed on an annual basis and will meet with designees from Discovery House, Inc to identify the mandatory requirements attached to this audit to prevent the reoccurrence of this citation in the future. This annual audit will meet the state standards and Discovery House, Inc. will assume responsibility for ensuring that this audit will be done annually hereafter unless otherwise deemed by the state auditing authority.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of the client records, the facility failed to provide a personal history that included detail in the areas of family history, legal history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history and sexual history in fourteen of fourteen records.
The findings include:
Ten records were reviewed for compliance with the regulations. Fourteen records did not document personal histories that included all components of a personal history that are comprised of family history, legal history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history, and sexual history. Specifically, patient records # 1,2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 14, 15, and 17
Record #1 - Client was admitted on 6-7-2010. The personal history failed to include information in the areas of legal history, military history, and recreational history.
Record #2 - Client was admitted on 6-16-2010. The facility failed to document a personal history to include educational history, military history, and recreational history.
Record #3 - Client was admitted on 9-29-2010. The facility failed to document a personal history to include military history, and recreational history.
Record #4 - Client was admitted on 11-10-2010. The facility failed to document a personal history to include military history, recreational history, and sexual history.
Record #5 - Client was admitted on 9-8-2010. The facility failed to document a personal history to include educational history and military history.
Record # 6 - Client was admitted on 11-3-2010. The facility failed to document a personal history to include military history, recreational history, and sexual history.
Record # 7 - Client was admitted on 11-29-2010. The facility failed to document a personal history to include employment/vocational history, educational history, military history, and sexual history.
Record # 8 - Client was admitted on 11-22-2010. The facility failed to document a personal history to include educational h history and military history.
Record # 9 - Client was admitted on 12-29-2010. The facility failed to document a personal history to include employment/vocational history, educational history, military history, and sexual history.
Record # 11 - Client was admitted on 11-1-2010. The facility failed to document a personal history to include family history, legal history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history, and sexual history.
Record # 12 - Client was admitted on 6-9-2010. The facility failed to document a personal history to include legal history, military history, and recreational history.
Record # 14 - Client was admitted on 7-28-2010. The facility failed to document a personal history to include educational history, military history, and sexual history.
Record # 15 - Client was admitted on 4-7-2010. The facility failed to document a personal history to include prior treatment, client's perception of drug use, family drug abuse history, employment/vocational history, military history, recreational history, and sexual history.
Record # 17 - Client was admitted on 4-26-2010. The facility failed to document a personal history to include family drug abuse history, legal history, military history, recreational history, and sexual history.
The facility director and clinical supervisor confirmed these findings.
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Plan of Correction
The Clinical Supervisor will develop and implement a process to review each pateint psychosocial history to ensure that it includes detail in the areas of family history, employment/vocational history, militry history, recreational history, prior treatment, client's perception of drug use, family drug abuse history and sexual history.
The target date for the development and implementation of the process is 3/30/2011. Development and implementation is complete; the Clinical Supervisor is reviewing each psychosocial to ensure it has adequate detail.
The Director is responsible for ensuring ongoing compliance. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on review of the facility's policy and procedure manual the facility failed to include a policy that included procedures for clients who transfer to another program.
The findings include:
The facility policy and procedure manual was reviewed on March 15, 2011. Based on the information in the project's Discharge Procedures Policy created in December 2003 and modified in November 2008. The policy indicated:
Follow up contacts
Discovery House collects post discharge outcome information that included:
- Obtaining evaluation of the program by the patient
- Collecting clinical information that compared the current status of the patients to their status at discharge and is used to measure treatment effectiveness.
- Provides and opportunity for re-engagement or referral if necessary.
- When a patient abruptly terminated follow-up will take place within 72 hours post discharge
- Regular follow-up will be made either phone or mail dependent on the expressed preference of the patient and the completion of the appropriate release
- The patients primary counselor or a designee will be responsible for follow-up attempts
- All attempts will be documented in the patient record.
The policy failed to include when a client has been discharged and referred to an outside resource, the project should, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral.
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Plan of Correction
Discovery House has developed a policy to include procedures for client's who transfer to another program.
The Program Director is responsible for ensuring the policy is followed. |