This report is a result of an onsite follow-up inspection regarding the plans of correction for the March 15, 2011 through March 17, 2011 licensure renewal inspection. The follow-up inspection was conducted on September 21, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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.
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Plan of Correction
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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 eight of eleven records.
The findings include:
Eleven records were reviewed for compliance with the regulations. Eight records did not document personal histories that included all components of a personal history that are comprised of family drug abuse 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 # 4, 5, 6, 7, 8, 9, 10, and 11.
Record #4 - Client was admitted on 5-23-2011. The personal history failed to include information in the area of educational history.
Record #5 - Client was admitted on 6-06-2011. The facility failed to document a personal history to include educational history.
Record #6 - Client was admitted on 7-20-2011. The facility failed to document a personal history to include recreational history.
Record #7 - Client was admitted on 5-9-2011. The facility failed to document a personal history to include military history.
Record #8 - Client was admitted on 8-3-2011. The facility failed to document a personal history to include sexual history and military history.
Record # 9 - Client was admitted on 8-17-2011. The facility failed to document a personal history to include family abuse and sexual history.
Record # 10 - Client was admitted on 8-24-2011. The facility failed to document a personal history to include client's perception of drug and alcohol use, family abuse, and sexual history.
Record # 11 - Client was admitted on 9-12-2011. The facility failed to document a personal history to include sexual history.
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Plan of Correction
The Clinical Supervisor completed an in-service to review the required information in the Initial Assessment on October 4, 2011.
The Clinical Team will ensure the initial Assessment includes details in the following areas: family history, legal history, employment/vocational history, education history, prior treatment, client's percetion of drug use, family drug abuse history and sexual history.
The Clinical Supervisor will audit all initial Assessments to ensure the information is included beginning October 11, 2011.
The Director is responsible for ensuring the in-service was completed and the audits are conducted. |