INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 13-17, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House Cu-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 January 1, 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 a review of employee training records and an interview with the facility director, the facility failed to document mandatory communicable disease training within one year of hire for four of five employees.
The findings included:
Twelve employee records were reviewed during the annual inspection on December 14 & 15, 2009. Of the twelve in the sample, five records belonged to clinical staff who were required to have the mandatory communicable disease training completed within one year of the hire date. Four of these records were missing the required mandatory communicable disease training as noted below:
Employee # 5 was hired 3/17/08. No documentation of the required six hour HIV/AIDS training was documented as of the inspection date on 12/15/09.
Employee # 7 was hired 1/28/08. No documentation of the required six hour HIV/AIDS training was documented as of the inspection date on 12/15/09.
Employee # 8 was hired 12/10/08. No documentation of the required six hour HIV/AIDS training was documented as of the inspection date on 12/15/09.
Employee # 10 was hired 1/6/08. No documentation of the required six hour HIV/AIDS training was documented as of the inspection date on 12/15/09.
On 12/14/09 at 1:15 PM the facility director was interviewed and acknowledged that not all staff were in compliance with the mandatory communicable disease training requirement.
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Plan of Correction
Once the Program Director realized the HIV/AIDS training was not completed all associates were scheduled prior to inspection. Effective immediately the program director will be responsible to schedule all new associate training within the first year to ensure that all mandatory trainings are completed as per 704.11.
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705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on observations of the physical plant by Division staff during the licensing inspection between the dates of December 14, 2009 at 11:30 AM and December 17, 2009 at 1 PM, the facility failed to ensure that there were at least two functional exits available for emergency egress.
The findings include:
Division staff arrived at the facility on December 14, 2009 at 11:30 AM. At that time, it was noted that construction was occurring at the rear of the facility and that the two stairways which allowed egress from the rear of the building were removed. The rear doors were not blocked off in any way to prevent someone from unwittingly using the rear exits. The drop from the doorway to the ground was approximately 4 feet. When the concern about this being a safety issue was mentioned to the facility director, yellow caution tape was placed across the two rear doors from inside the facility. The facility director stated that the construction was being done to meet code requirements for the new modular unit which was to be installed on December 15 or 16, 2009. In order to accomplish the required construction, the construction workers removed the rear stairs which permitted emergency egress from the two rear exits. This created a situation which resulted in only one functioning exit located at the front of the facility for the period 12/14/09-12/17/09. There was no second means of egress from the facility. Division staff left the premises at approximately 1 PM on 12/17/09 and the two rear exits were still not operational nor had the additional modular unit been set in place. The facility failed to ensure that at least two means of egress, at least 15 feet apart, were available during all hours of operation.
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Plan of Correction
Effective immediately the construction crew is onsite replacing the rear doors which permits emergency egress from the two rear exits. The Program Director is totally responsible to ensure construction continues until the rear exits are in place. The Program Director will view all plans prior to constuction to ensure that there is an alternate exit prior to begining construction. |
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 the review of the facility safety manual and an interview with the facility director, the facility failed to document fire drills each month during 2009.
The findings include:
The fire drill log contained in the safety manual was reviewed on 12/14/09. At that time, Division staff noted that documentation did not include a monthly fire drill but substituted a disaster drill. Documentation for the disaster drill of 5/9/09 stated that it was a medical emergency which did not require building evacuation.. No fire drill was documented for the month of May 2009. The facility director was interviewed on 12/14/09 and stated she was under the impression that disaster drills could be substituted for the fire drill requirement. This is a repeat citation . This issue was also cited during the licensing inspection completed on 11/14/2008. The plan of correction stated that fire drills would be held monthly beginning on 12/3/08.
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Plan of Correction
The Program Director will have an individual training with the Health and Safety Captain to ensure that disaster drills will not replace a fire drill. The Health and Safety Captain will conduct unannounced fire drills at least once per month. The Program Director will monitor the Health and Safety manual to ensure monthly fire drills are documented 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 a review of fiscal documents presented at the time of the inspection and an interview with the facility director, the facility failed to document an annual audit of financial activities for the year ended 12/31/08.
The findings included:
During the onsite licensing inspection conducted from December 14 to 17, 2009, 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.
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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". The Director will be resposible to ensure compliance.
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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 and an interview with the facility director , the facility failed to obtain an informed and voluntary consent for each release of client identifying information documented in 22 of 24 client records.
The findings include:
Twenty four records were reviewed during the onsite inspection between December 14 and 19, 2009. Documentation of billing records was reviewed in each file . Twenty two client records included documentation of releases of client identifying information to managed care funding entities without the clients' consent to release information to these entities. The facility director was interviewed on 12/15/09 at 12:10 PM when the facility director confirmed that the consent to release information forms had not been obtained. The facility director indicated that it was believed that the consent to release information forms obtained to allow for the release of information to the Department of Public Welfare's County Assistance Offices was sufficient to permit disclosures to the managed care contractors for the Department of Public Welfare.
The specific findings include:
Client # 1 was admitted on 8/5/09 and discharged on 10/13/09. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer for the duration of the treatment episode.
Client # 2 was admitted on 9/2/09 and discharged on 10/8/09. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer for the duration of the treatment episode.
Client # 3 was admitted on 5/9/09 and discharged on 9/30/09. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer for the duration of the treatment episode.
Client #4 was admitted on 6/20/09 and discharged on 10/19/09. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer for the duration of the treatment episode.
Client # 5 was admitted on 8/31/09 and discharged on 10/13/09. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer for the duration of the treatment episode.
Client # 6 was admitted on 8/28/09 and was still active at the time of the inspection. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer as of 12/17/09.
Client # 7 was admitted on 7/16/09 and was still active at the time of the inspection. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer as of 12/17/09.
Client # 8 admitted 8/24/09 and was still active at the time of the inspection. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer as of 12/17/09.
Client # 9- admitted 12/3/09 and was still active at the time of the inspection. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer as of 12/17/09.
Client # 10 admitted 1/29/09 and was still active at the time of the inspection. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer as of 12/17/09.
Client # 11 admitted 5/8/09 and was still active at the time of the inspection. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer as of 12/17/09.
Client # 13 admitted 12/3/09 and was still active at the time of the inspection. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer as of 12/17/09.
Client # 14 admitted 9/21/09 and was still active at the time of the inspection. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer as of 12/17/09.
Client # 15 admitted 8/19/09 and was still active at the time of the inspection. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer as of 12/17/09.
Client # 16 admitted 5/14/09 and was still active at the time of the inspection. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer as of 12/17/09.
Client # 18 admitted 10/19/09 and was still active at the time of the inspection. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer as of 12/17/09.
Client # 19 admitted 10/19/09 and was still active at the time of the inspection. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer as of 12/17/09.
Client # 20 admitted 5/14/09 and was still active at the time of the inspection. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer as of 12/17/09.
Client # 21 admitted 3/26/09 and was still active at the time of the inspection. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer as of 12/17/09.
Client # 22 admitted 3/16/09 and was still active at the time of the inspection. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer as of 12/17/09.
Client # 23 admitted 7/28/09 and was still active at the time of the inspection. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer as of 12/17/09.
Client # 24 admitted 9/21/09 and was still active at the time of the inspection. Billing records, demonstrating releases of client identifying information to a third party payer, were documented in the electronic record but there were no corresponding consent to release information forms permitting a release of information to that third party payer as of 12/17/09.
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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 will do sporadic checks to monitor compliance. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records and an interview with the facility director , the facility failed to document either the type of treatment services and/or the frequency at which the services were to occur on the treatment plans in 19 of 19 client records.
The findings included:
During the annual onsite licensing inspection conducted from 12/14/2009 to 12/17/2009, 19 client records were reviewed. The treatment plans documented in 19 of 19 client records failed to include either the type or the frequency of treatment or both.
The treatment plans in client records # 1, 7, 8, 10, 11, 12, 16 and 17 did not include documentation of the type of services that would be provided to the client.
The treatment plans in client records # 2, 3, 4, 6, 15 and 18 did not include documentation of the frequency at which the services would be provided to the client.
The treatment plans in client record # 14 did not include documentation of the type and frequency at which services would be provided to the client.
The facility director was interviewed on 12/14/09 and acknowledged the failure to document either the type and/or the frequency of treatment on all treatment plans.
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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 and frequency of service that will be provided for the patient. The Clinical Supervisor will also address this individually in supervision to ensure compliance by each counselor. The Clinical Supervisor will monitor prior to approval of the treatment plan. The Program Director will do sporadic checks to ensure compliance.
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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 on December 14-17, 2009 the facility failed to document a proposed type of support service on each treatment plan in 8 of 19 client records.
The findings include:
Treatment plans in client records # 1, 2, 3, 8, 11, 12, 14 and 17 did not include documentation of the proposed support services.
Client # 1 was admitted on 8/5/09 and the treatment plan was documented on 9/19/09.
Client# 2 was admitted on 9/2/09 and the treatment plan was documented on 10/01/09.
Client # 3 was admitted on 5/9/08 and the treatment plan was documented on 6/3/08.
Client # 8 was admitted on 8/21/09 and the treatment plan was documented on 9/24/09.
Client # 11 was admitted on 5/8/09 and the treatment plan was documented on 6/4/09.
Client # 12 was admitted on 6/11/09 and the treatment plan was documented on 7/24/09.
Client # 14 was admitted on 7/24/09 and the treatment plan was documented on 8/24/09.
Client # 17 was admitted on 9/21/09 and the treatment plan was documented on 10/28/09.
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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.
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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 client records completed between December 14- 17, 2009 the facility failed to document aftercare plans which were completed within the time frames specified in written facility policy in 8 of 19 client records and failed to include time frames for each goal in 10 of 19 client records.
The findings included:
Written facility policy requires that an aftercare plan be documented on each client within fourteen days of admission. Facility policy states that aftercare plans are to include goals with time frames. Nineteen client records were reviewed and each was required to have a complete aftercare plan documented within fourteen days of admission and to include time frames for each aftercare goal. Client records # 2, 3, 5, 7, 11, 12, 16 and 19 did not contain aftercare plans that were documented within 14 days of admission. The aftercare plans in client records # 3, 5, 6, 7, 11, 12, 15, 16, 17 and 19 did not include documentation of time frames for the aftercare goals.
Client # 2 was admitted on 9/2/09 and the aftercare plan was documented on 9/21/09.
Client # 3 was admitted on 5/9/08 and the aftercare plan was documented on 6/3/08.
Client # 5 was admitted on 8/21/09 and the aftercare plan was documented on 10/09/09.
Client # 7 was admitted on 7/16/09 and the aftercare plan was documented on 8/24/09.
Client # 11 was admitted on 5/8/09 and the aftercare plan was documented on 6/14/09.
Client # 12 was admitted on 6/11/09 and the aftercare plan was documented on 7/13/09.
Client # 16 was admitted on 5/14/09 and the aftercare plan was documented on 6/19/09.
Client # 19 was admitted on 10/19/09 and the aftercare plan was documented on 11/20/09.
Client # 6 was admitted on 8/28/09 and the aftercare plan was documented on 9/02/09.
Client # 15 was admitted on 8/19/09 and the aftercare plan was documented on 9/03/09.
Client # 17 was admitted on 9/21/09 and the aftercare plan was documented on 10/5/09.
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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 he counselor. The Clinical Supervisor will monitor compliance through the admission chart audit. The Program Director will do sporadic checks to ensure compliance.
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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 between December 14 and 17, 2009, the facility failed to include the reasons for treatment and the services provided to the client on the discharge summaries in three of six client records.
The findings included:
The discharge summaries in client records # 1, 3 and 4 were incomplete as follows:
Client # 1 was admitted on 8/5/09 and discharged on 10/27/09. The discharge summary was completed on 11/19/09. The discharge summary failed to include documentation of the reasons for treatment and failed to list all of the services offered. The facility failed to document on the discharge summary that individual and group treatment sessions were provided to the client.
Client # 3 was admitted on 5/9/08. The discharge date was 9/30/09. The discharge summary failed to include documentation of a complete summary of the services offered. The facility failed to document on the discharge summary that individual and group treatment sessions were provided to the client.
Client # 4 was admitted on 6/20/09. The discharge date was 10/19/09. The discharge summary failed to include documentation of a complete summary of the services offered. The facility failed to document on the discharge summary that individual and group treatment sessions were provided to the client.
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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 he counselor. The Clinical Supervisor will monitor discharge summaries to for compliance. The Program Director will do sporadic checks to ensure compliance.
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