INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 9 through April 11, 2013, 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.
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of administrative documentation, the facility failed to document an overall plan for addressing training needs, as required by regulation.
The findings include:
On February 9, 2013, the policy and procedures were reviewed. Per the agency policy and procedure manual the clinic training plan will be completed by February 1st. The regulation requires an overall plan for addressing training needs to be completed as a component of a staff development program. The facility failed to document the completion of an overall training plan that included subjects, trainers and dates of training.
This was reviewed with the facility director on April 9, 2013 at 1:50 p.m. The facility director confirmed that a plan for addressing training needs of staff did not include the required components.
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Plan of Correction
The Director will develop an overall clinic training plan that includes subjects, trainers, and dates of training offered by February 1st of each year.
The plan will address the clinic training needs as a component of the staff development program.
The program director is rspnsible for developing the plan by February 1st of each year. |
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 a review of training documentation, the facility failed to provide complete individual training plans for four of six personnel records reviewed.
The findings include:
Seven personnel records were reviewed on February 9, 2013. Individual training plans were required in all personnel records. The individual training plans in employee records # 2, 3, 5, and 6 were identical and did not include the training topics that were documented on the employees' training needs assessment.
This finding was discussed with the facility director on February 9, 2013 and was not disputed.
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Plan of Correction
The Clinical Supervisor or designee will develop complete individual training plans for each staff member by February 1st of each year.
The Director provided a brief in-service with the Clinical Supervisor to review the standard and expectations associated with the development of individual training plans.
The Director is responsible for ensuring compliance with the standard by reviewing the training plans by February 1st of each year. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on April 9, 2013. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. Twelve months of documented fire drills were reviewed. The facility documented an alternate exit for one month out of twelve months reviewed. Nine of the twelve months used both exits and two months failed to indicate what exits were used.
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Plan of Correction
The Safety Committee Chairperson or designee will ensure that alternate exit routes are prepared during fire drills. The alternate exit routes will be designated on the Fire Drill Form.
The Director provided a brief in-service on the standard and expectations for a fire drill at the clinic.
The Director is responsible for ensuring that alternate exit routes are designated during a fire drill and documented on the Fire Drill Form beginning 6/3/13. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documentation, the project failed to develop goals and objectives for the 2013 calendar year.
The findings were:
A review of administrative documents on April 9, 2013 indicated that the annual goals and objectives for the 2013 calendar year were not complete. The three year Strategic Plan that was documented covered a time period of 2009 through 2012. The facility director presented the licensing specialist with facility specific goals and objectives, however, they failed to include time frames and available resources.
A discussion with the facility director on April 9, 2014 confirmed that the project's strategic plan has not been distributed to the facility and was due to be presented at the end of April through a webinar.
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Plan of Correction
The project director will ensure the 3-year Strategic Plan is current. I Program Director will ensure the clinic plan includes specific goals and objectives with timeframes.
The project Strategic Plan is complete.
The program director will ensure that the development of clinic goals and objectives include timeframes by February 1st each year. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical and psychiatric coverage.
The findings include:
The letters of agreement were reviewed on April 9, 2013. The only letter of agreement regarding 24- hour emergency medical and psychiatric coverage was signed with a local hospital on March 23, 2010 by the previous director. The agreement stipulated that it was in effect for two years and could be renewed for another two years upon mutual agreement of both parties. There was no documentation of another two year agreement in place with the new facility director. The agreement expired on March 23, 2012. There was no other documentation of a 24- hour emergency medical and psychiatric coverage agreement.
The facility director was interviewed on April 9, 2013 and confirmed no other documentation of a 24- hour emergency medical and psychiatric coverage was available.
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Plan of Correction
The program director secured a written agreement with a licensed hospital for 24-hour emergency medical and psychiatric coverage.
The Director will ensure a signed agreement remains in effect for the 24-hour emergency medical and psychiatric coverage.
The program director is responsible for ensuring the 24-hour emergency medical and psychiatric coverage agreement is active. |
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 patient records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in two fifteen records reviewed. The facility also exceeded 4 Pa. Code, Subsection 255.5(b) in three of fifteen records reviewed.
The findings included:
Eighteen patient records were reviewed February 9 - 11, 2013. Fifteen records were reviewed regarding release of information documentation. The facility failed to ensure that an informed and voluntary consent to release information was obtained in two patient records reviewed, # 6 and 7. Additionally, records # 2, 3, 14 and 15 included documentation that exceeded 4 Pa. Code, Subsection 255.5(b).
Patient record # 2 contained a consent to release for an insurance company that permitted the release of financial information, current dose and level, lab work results, treatment plan, drug test results, discharge summary and intake summary. These items exceeded 4 Pa. Code, Subsection 255.5(b) for what is permitted to be released to an insurance company.
Patient record # 3 contained a consent to release for an insurance company that permitted the release of medication history, financial information, current dose and level, drug test results, and discharge summary. These items exceeded 4 Pa. Code, Subsection 255.5(b) for what is permitted to be released to an insurance company.
Patient record #6 contained information that the patient was being funded by an insurance provided. A review of the record revealed that there was no consent to release signed by the patient for the insurance company.
Patient record # 7 contained information the patient began receiving insurance benefits on 3/29/2013. The counselor met with the patient on 3/29/2013 and documented in the progress notes and treatment plan that he was now receiving government medical benefits. The counselor failed to obtain a consent to release of information for this provider.
Patient record # 14 contained a consent to release for an insurance company that permitted the release of financial information and discharge summary. These items exceeded 4 Pa. Code, Subsection 255.5(b) for what is permitted to be released to an insurance company.
Patient record # 15 contained a consent to release for an insurance company that permitted the release of medication history, financial information, current dose and level, lab work results, treatment plan, drug test results, discharge summary and intake summary. These items exceeded 4 Pa. Code, Subsection 255.5(b) for what is permitted to be released to an insurance company.
This finding was discussed with the facility director and clinical supervisor and was not disputed.
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Plan of Correction
The Clinical Supervisor will provide an in-service by 5/27/13 to reinforce the importance of obtaining a release of information prior to releasing any information. The same in-service will also stress the importance of only releasing information that is authorized by the release of information. The Clinical Supervisor will document the training in the clinic training log.
The Clinical Supervisor will audit random charts to ensure compliance with the standard beginning 6/3/13
The Director will ensure the in-service is completed and is responsible for ensuring the process for a release of information is followed. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on the review of clinical documentation, the facility failed to document the basis for determining current and one year dependency in two of two record reviewed.
The findings include:
Eighteen patient records were reviewed on April 9-11, 2013. Two patient record were reviewed for physician documentation of the basis for determining current and one year history of dependency. The facility failed to document dependency for one year prior to the admission in patient records # 1 and 2.
Patient # 1 was admitted on January 2, 2013. Review of the patient record revealed the patient had been in a detox program in the past year. The patient attended a detoxification program in October 2012. The patient failed to meet the one year dependency requirement and the facility did not submit an exception request to the Department for this admission.
Patient # 2 was admitted on December 21, 2012. Review of the patient record revealed the patient had attended three detox programs in the past year. Documentation in the patient record showed the patient was admitted into a detox program in March, May and November of 2012. The patient failed to meet the one year dependency requirement and the facility did not submit an exception request to the Department for this admission.
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Plan of Correction
The Director will review State of PA 715.9(a)(4) with the physicians by May 13, 2013 to ensure that all potential patients meet the current and on year dependency requirement or complete an exception request and send the request to the Department this admission.
The Director will conduct random auits of charts to ensure the physicians follow the standard.
The program director is responsible for ensuring the compliance with the State of PA 715.9(a)(4)standard. |
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 patient records, the facility failed to document a complete personal history in seven of eight records reviewed.
The findings include:
Eighteen patient records were reviewed April 9 - 11, 2013. Eight patient records were reviewed for a personal history that included prior treatment, family, legal, employment/vocation, educational, military, recreational, and sexual history. Patient records # 1, 2, 4, 6, 7 and 8 lacked detailed personal histories. The historical data recorded consisted of one word responses.
Patient # 1 was admitted on 1/2/2013. The facility failed to document a detailed employment/vocational history, educational history and sexual history.
Patient # 2 was admitted on 12/21/2012. The facility failed to document a detailed legal history and sexual history.
Patient # 4 was admitted on 11/2/2012. The facility failed to document a detailed educational history and sexual history.
Patient # 5 was admitted on 11/5/2012. The facility failed to document a detailed sexual history.
Patient # 6 was admitted on 12/7/2012. The facility failed to document a detailed legal history, educational history and sexual history.
Patient # 7 was admitted on 1/30/2013. The facility failed to document a detailed legal history, educational history and sexual history.
Patient # 8 was admitted on 12/17/2012. The facility failed to document a detailed sexual history.
The findings were reviewed with the facility director and clinical supervisor and were not disputed.
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Plan of Correction
The Clinical Supervisor will provide an in-service on the standard and expectation to provide a complete personal history. The in-service will stress the requirement for detailed historical data. The in-service will be completed and documented by 5/27/13.
The Clinical Supervisor or designee will randomly audit charts to ensure compliance beginning 6/3/13.
The program director is responsible for ensuring the completion fo the in-service and random audits to ensure compliance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of patient records, the facility failed to document psychosocial evaluations that provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in eight of eight records reviewed.
The findings included:
On April 9-11, 2013, eighteen patient records were reviewed. Eight of the records were reviewed for the content of the psychosocial evaluation. Patient records # 1, 2, 3, 4, 5, 6, 7, and 8 failed to include a psychosocial evaluation that included a composite picture of the client's problems and needs to be addressed in treatment, the client's assets and strengths, coping mechanisms, support systems, the negative factors that might inhibit treatment, and the counselor's impressions regarding the patient. The documentation included a repeat of the patient reported information and did not include an evaluation by the clinician for all required components.
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Plan of Correction
The Clinical Supervisor will provide an in-service by May 27, 2013 to re-educate clinical staff on how to document psychosocial evaluations that provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions, and causes leading to the clinent's current situation.
The clinical supervisor or designee will randomly audit charts to ensure compleiance with the standard by 6/3/13.
The program director is responsible for ensuring the in-service is completed, the standard is followed, and the random audits are completed. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of patient records, the facility failed to document case consultations that included the names of the persons attending and their disciplines in six of fifteen records reviewed.
The findings include:
Eighteen patient records were reviewed. Fifteen records were reviewed for documentation of case consultation that included the persons attending the case consultation and their disciplines. The facility failed to document who was in attendance for the case consultations documented in patient records # 1, 5, 8, 9, 11 and 13.
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Plan of Correction
The Clinical Supervisor will provide an in-service to review the statndard of documenting the names and disciplines of those individuals attending the case consultations by May 20, 2013.
The Clinical Supervisor or designee will review each case consultation to ensure the standard is met by 6/3/13.
The program director is responsible for ensuring the in-service is completed and the standard is met by 6/3/2013. |