INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the December 17, 2009 licensure renewal inspection. The follow-up inspection was conducted on May 25, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 June 18, 2010.
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Plan of Correction
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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 administrative materials presented at the inspection , and an interview with the facility director, the facility failed to document an audit for the 2009 fiscal year.
The findings included:
The facility director was asked to provide documentation of the most recent audit completed by the Project. The document presented was not an audit but was identified in the text of the document as a financial compilation. The documentation indicated that information presented included financial statements of assets, liabilities and stockholder's deficit and statements of revenues, expenses and accumulated deficit. The text of the letter written by the accountants stated that "We have not audited or reviewed the accompanying financial statements and supplementary schedules and accordingly, do not express an opinion or any other form of assurance on them."
The facility director indicated that this was the only documentation available from the corporate office and that no audit was available for the 2009 fiscal year. The financial statements presented covered the period from December 31, 2008 and 2007.
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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 discussion with the facility director and administrative assistant, the facility failed to ensure that a valid consent to release client identifying information was in place prior to each release of information in two of five patient records reviewed.
The findings included:
Five client records were reviewed during the onsite inspection. Each was required to have a consent to release client identifying information prior to any such disclosures. The facility plan of correction from the December 2009 inspection, when this issue was originally identified, indicated that the issue would be corrected effective 1/14/2010. Two of five records reviewed were noted to have disclosures of information without valid consent documented subsequent to the correction date specified in the plan of correction.
Record # 1- the record included documentation of a release of information to a Healthchoices contractor without a valid consent to release information. The client was admitted on 5/13/10.
Record # 2 - The client was admitted on 3/25/10 and a disclosure of client information to a Healthchoices contractor was documented on 3/28/10 without a valid consent to release information documented in the client record.
The issue was reviewed and discussed with the facility director and administrative assistant and they were given the opportunity to dispute this finding. They acknowledged that these findings were valid.
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Plan of Correction
The Program Director held training on 6/7/10 regarding the importance of having a valid consent to release information from the patient record. Effective 6/30/10 there will be a check list for all new admissions to make sure there that the consent is signed prior to admission. The clinical supervisor will monitor all new admission releases. 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 and an interview with clinical staff, the facility failed to document the proposed type of support services on each client treatment plan in three of three client records.
The findings included:
Five client records were reviewed during the onsite inspection. Three client records were required to include documentation of treatment plans which included documentation of the proposed type of support services to be offered to each client. The plan of correction submitted subsequent to the December 2009 inspection indicated that the date of correction for this issue would be 1/14/10.
Record # 2- admitted 3/25/10 included documentation of a treatment plan which did not identify support services.
Record # 3- admitted 3/11/10 included documentation of a treatment plan which did not identify support services.
Record # 5- admitted 2/14/10 included documentation of a treatment plan which did not identify support services.
The issue was reviewed and discussed with the facility director, administrative assistant and clinical staff, they were given the opportunity to dispute this finding. They acknowledged that these findings were valid.
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Plan of Correction
The Program Director held a meeting on 6/8/10 regarding documentation of proposed support services in an individual treatment plan. Effective 6/30/10 prior to completion of the treatment plan both the clinical supervisor and the lead counselor will review each plan prior to approving the plan to ensure the support services are included. The program director will do sporadic checks to monitor 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 onsite inspection, the facility failed to document discharge summaries which addressed the services offered to the client in two of two client records.
The findings include:
During the onsite inspection of May 25, 2010, records of two discharged clients were reviewed. The issue identified at the December, 2009 licensing inspection identifying the failure to complete comprehensive documentation of the services offered to each client on the discharge summary was to be corrected by 1/14/2010.
Record # 4- admitted 8/5/09 and discharged 4/14/10. The discharge summary did not address individual and group services offered to the client even though these services were identified in progress notes and the service record in the client record documentation.
Record # 5- admitted 2/14/10 and discharged 3/24/10. The discharge summary did not address individual and group services offered to the client even though these services were identified in progress notes and the service record in the client record documentation.
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Plan of Correction
The Program Director held a training on 6/7/10 regarding the importance of documenting the proposed support services that were offered to each client. Effective 6/30/10 prior to the completion of each discharge summary the clinical supervisor and the lead counselor will be notified to review the unfinished version to ensure the proposed support service is documented. When approved the discharge summary will then be documented as complete. The Program Director will do sporadic checks to monitor compliance.
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