INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 12 & 13, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House - NC 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 February 8, 2010.
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Plan of Correction
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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 a review of the facility's fire drill log and an interview with the facility director, the facility failed to conduct a fire drill during the month of June 2009.
The findings include:
The fire drill log was reviewed and the facility director was interviewed on January 13, 2010. There was no documentation of the June 2009 dire drill in the log. The facility director confirmed that the June 2009 fire drill was not conducted.
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Plan of Correction
The Program Director will facilitate a training with the Health and Safety Team focused on fire safety regulations. 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 fire drills are conducted monthly and 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 the review of facility financial documents during the onsite licensing inspection, the facility failed to document an audit for the year ended 12/31/2008.
The findings included:
Division staff reviewed the documentation presented when the annual audit was requested. The documentation presented by the facility director consisted of a financial statement for the year ended 12/31/08. The letter from the accountant stated"...we have not audited or reviewed the accompanying financial statements and do not express an opinion or any other form of assurance on them." There is a statement of income and expenses and balances. The documentation presented failed to meet the requirement for the annual financial 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 Program Director will be responsible to monitor compliance. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records and the treatment plans included in those patient records, the electronic data in the Smart System and interviews with the facility director and the clinical supervisor, the facility failed to ensure that patients received a minimum of 2.5 hours of counseling, on average, per month in accordance with the directives in the treatment plans in five of fifteen patient records.
The findings include:
Fifteen patient records were reviewed during the inspection conducted from January 12, 2010 through January 13, 2010. The treatment plans in all fifteen patient records listed the minimum amount of treatment that was to be provided to the patient per month. One patient record reviewed only required an average of 0.5 hours per month. Fourteen patient records required a minimum of 2.5 hours of counseling per month on average. The treatment provided to the patients represented by the patient records reviewed was averaged out over the last three months. The patients represented by patient records # 8, 12, 13, 14 and 15 failed to obtain an average of 2.5 hours of counseling over the last three months.
Patient # 8 was admitted on 10/7/09. Her last counseling session was on 12/17/09. She received an average of 1.5 hours of counseling per month for the months of October 2009, November 2009 and December 2009.
Patient # 12 was admitted on 8/17/09. His last counseling session was on 12/24/09. He received an average of 2.16 hours of counseling per month for the months of October 2009, November 2009 and December 2009.
Patient # 13 was admitted on 8/3/09. His last counseling session was on 12/2/09. He received an average of 1.8 hours of counseling per month for the months of October 2009, November 2009 and December 2009.
Patient # 14 was admitted on 7/15/09. Her last day of counseling was on 12/17/09. She received an average of 1.75 hours of counseling per month for the months of October 2009, November 2009 and December 2009.
Patient # 15 was admitted on 8/9/09. Her last day of counseling was on 12/29/09. She received an average of 1.87 hours of counseling per month for the months of October 2009, November 2009 and December 2009.
The facility director and the clinical supervisor were interviewed on January 12 and January 13, 2010 and confirmed that this has been a problem area. They did provide documentation to demonstrate that progress has been made to correct this issue and that the plan of correction is ongoing.
This is a repeat citation from the methadone monitoring inspection conducted on September 3, 2009.
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Plan of Correction
The Clincai Supervisor will implement weekly reviews of required and provided direct service hours. Compliance will be addressed during weekly clinical team meetings and individual clinical supervision. Action Plans will be required when counselors do not provide ample psychotherapy services. Timeframe to implement is immediate and ongoing. The Program Director and Clinical Supervisor will be responsible for oversight. |
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 patient records and interviews with the facility director and the clinical supervisor, the facility failed to document complete personal histories in 11 of 13 patient records.
The findings include:
Fifteen patient records were reviewed between January 12, 2010 and January 13, 2010. Interviews were conducted with the facility director and the clinical supervisor on the same dates. Two of the patient records reviewed included personal histories which had been reviewed during a previous licensing inspection. Twelve of thirteen patient records failed to include complete personal histories. The twelve patient records did not include documentation addressing educational histories and employment histories. The intake documents in the eleven patient records discussed current employment and educational status, but failed to provide information on the patients' history in those two areas.
Patient # 1 was admitted to treatment on 9/30/09. The intake and admission paperwork, including the personal history was completed between 9/30/09 and 10/2/09. The educational history and the employment/vocational history sections addressed only the current status and did not provide the patient's history for these two areas.
Patient # 2 was admitted to treatment on 10/2/09. The intake and admission paperwork, including the personal history was completed between 10/2/09 and 10/6/09. The educational history and the employment/vocational history sections addressed only the current status and did not provide the patient's history for these two areas. This information was not updated as of 1/13/2010.
Patient # 3 was admitted to treatment on 10/2/09. The intake and admission paperwork, including the personal history was completed between 10/2/09 and 10/6/09. The educational history and the employment/vocational history sections addressed only the current status and did not provide the patient's history for these two areas. This information was not updated as of 1/13/2010.
Patient # 4 was admitted to treatment on 8/6/09. The intake and admission paperwork, including the personal history was completed between 8/6/09 and 8/10/09. The educational history and the employment/vocational history sections addressed only the current status and did not provide the patient's history for these two areas. This information was not updated as of 1/13/2010.
Patient # 5 was admitted to treatment on 11/18/09. The intake and admission paperwork, including the personal history was completed between 11/18/09 and 11/20/09. The educational history history section addressed only the current status and did not provide the patient's history for that area. This information was not updated as of 1/13/2010.
Patient # 6 was admitted to treatment on 11/18/09. The intake and admission paperwork, including the personal history was completed between 11/18/09 and 11/20/09. The educational history and the employment/vocational history sections addressed only the current status and did not provide the patient's history for these two areas. This information was not updated as of 1/13/2010.
Patient # 7 was admitted to treatment on 10/30/09. The intake and admission paperwork, including the personal history was completed between 10/30/09 and 11/4/09. The educational history and the employment/vocational history sections addressed only the current status and did not provide the patient's history for these two areas. This information was not updated as of 1/13/2010.
Patient # 9 was admitted to treatment on 9/18/09. The intake and admission paperwork, including the personal history was completed between 9/18/09 and 9/22/09. The educational history and the employment/vocational history sections addressed only the current status and did not provide the patient's history for these two areas. This information was not updated as of 1/13/2010.
Patient # 12 was admitted to treatment on 8/17/09. The intake and admission paperwork, including the personal history was completed between 8/17/09 and 8/19/09. The educational history and the employment/vocational history sections addressed only the current status and did not provide the patient's history for these two areas. This information was not updated as of 1/13/2010.
Patient # 13 was admitted to treatment on 8/3/09. The intake and admission paperwork, including the personal history was completed between 8/3/09 and 8/5/09. The educational history and the employment/vocational history sections addressed only the current status and did not provide the patient's history for these two areas. This information was not updated as of 1/13/2010.
Patient # 14 was admitted to treatment on 7/15/09. The intake and admission paperwork, including the personal history was completed between 7/15/09 and 7/17/09. The educational history and the employment/vocational history sections addressed only the current status and did not provide the patient's history for these two areas. This information was not updated as of 1/13/2010.
Patient # 15 was admitted to treatment on 8/19/09. The intake and admission paperwork, including the personal history was completed between 8/19/09 and 8/21/09. The educational history and the employment/vocational history sections addressed only the current status and did not provide the patient's history for these two areas. This information was not updated as of 1/13/2010.
During an interview with the facility director and the clinical supervisor on January 12, 2010, they confirmed that the data collected for educational and employment histories was current status and did not always include the historical perspective.
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Plan of Correction
An in-service training will be provided by the Clinical Supervisor for all clinical staff involved in the intake and admissions process. The training will address the documentation of personal histories and techniques on how to obtain the information. The Clinical Supervisor will be responsible to review psychosocial evaluations during clinical quality reviews to ensure compliance. Program Director will be responsible for oversight. |
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 a review of client records, and an interview with the facility director and the clinical supervisor, the facility failed to include written documentation of the proposed type of support service on the individual treatment and rehabilitation plans, in twelve of twelve patient records.
The findings include:
Fifteen patient records were reviewed between January 12, 2010 and January 13, 2010. The treatment plans in three of the patient records had been reviewed during a previous licensing inspection. The individual treatment and rehabilitation plans were required to include documentation of the proposed type of support services on the treatment plans in fifteen patient records reviewed. The facility did not document the proposed type of support services on the treatment plans in patient records # 1, 2, 3, 4, 6, 7, 8, 9, 12, 13, 14 and 15.
Patient # 1 was admitted on 9/30/09. The individual treatment and rehabilitation plan was completed on 11/2/09. There was no documentation of support services in the treatment plan. This had not been corrected or updated as of 1/13/2010.
Patient # 2 was admitted on 10/2/09. The individual treatment and rehabilitation plan was completed on 11/3/09. There was no documentation of support services in the treatment plan. This had not been corrected or updated as of 1/13/2010.
Patient # 3 was admitted on 10/2/09. The individual treatment and rehabilitation plan was completed on 10/11/09. There was no documentation of support services in the treatment plan. This had not been corrected or updated as of 1/13/2010.
Patient # 4 was admitted on 8/6/09. The individual treatment and rehabilitation plan was completed on 8/23/09. There was no documentation of support services in the treatment plan. This had not been corrected or updated as of 1/13/2010.
Patient # 6 was admitted on 11/18/09. The individual treatment and rehabilitation plan was completed on 12/15/09. There was no documentation of support services in the treatment plan. This had not been corrected or updated as of 1/13/2010.
Patient # 7 was admitted on 10/30/09. The individual treatment and rehabilitation plan was completed on 11/30/09. There was no documentation of support services in the treatment plan. This had not been corrected or updated as of 1/13/2010.
Patient # 8 was admitted on 10/7/09. The individual treatment and rehabilitation plan was completed on 11/18/09. There was no documentation of support services in the treatment plan. This had not been corrected or updated as of 1/13/2010.
Patient # 9 was admitted on 9/18/09. The individual treatment and rehabilitation plan was completed on 10/24/09. There was no documentation of support services in the treatment plan. This had not been corrected or updated as of 1/13/2010.
Patient # 12 was admitted on 8/17/09. The individual treatment and rehabilitation plan was completed on 9/14/09. There was no documentation of support services in the treatment plan. This had not been corrected or updated as of 1/13/2010.
Patient # 13 was admitted on 8/3/09. The individual treatment and rehabilitation plan was completed on 8/31/09. There was no documentation of support services in the treatment plan. This had not been corrected or updated as of 1/13/2010.
Patient # 14 was admitted on 7/15/09. The individual treatment and rehabilitation plan was completed on 8/7/09. There was no documentation of support services in the treatment plan. This had not been corrected or updated as of 1/13/2010.
Patient # 15 was admitted on 8/9/09. The individual treatment and rehabilitation plan was completed on 9/9/09. There was no documentation of support services in the treatment plan. This had not been corrected or updated as of 1/13/2010.
The facility director confirmed that some of the counselors were not documenting support services on the treatment plans, as required. The facility director confirmed that staff will be provided additional training on documentation of the proposed type of support services.
This is a repeat citation from the licensing inspection of December 16, 2008. The facility was found to be in non compliance with 28 Pa. Code Subsection 715.23 (d)(1) for failure to include support services on the treatment plans during the methadone monitoring inspection of September 3, 2009.
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Plan of Correction
The Program Director and Clinical Supervisor will hold an in-service training on patient treatment planning. The training will focus on documenting the proposed type of support services for each patient. The Clinical Supervisor will address the documentation requirement in weekly clinical supervision to ensure compliance. The Clinical Supervisor will monitor prior to approval of treatment plans. The Program Director will do sporadic chart audits for oversight. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of patient records and the treatment plans included in those patient records, the electronic data in the Smart System and interviews with the facility director and the clinical supervisor, the facility failed to ensure that patients received a minimum of 2.5 hours of counseling, on average, per month in accordance with the directives in the treatment plans in five of fifteen patient records.
The findings include:
Fifteen patient records were reviewed during the inspection conducted from January 12, 2010 through January 13, 2010. The treatment plans in all fifteen patient records listed the minimum amount of treatment that was to be provided to the patient per month. One patient record reviewed only required an average of 0.5 hours per month. Fourteen patient records required a minimum of 2.5 hours of counseling per month on average. The treatment provided to the patients represented by the patient records reviewed was averaged out over the last three months. The patients represented by patient records # 8, 12, 13, 14 and 15 failed to obtain an average of 2.5 hours of counseling over the last three months.
Patient # 8 was admitted on 10/7/09. Her last counseling session was on 12/17/09. She received an average of 1.5 hours of counseling per month for the months of October 2009, November 2009 and December 2009.
Patient # 12 was admitted on 8/17/09. His last counseling session was on 12/24/09. He received an average of 2.16 hours of counseling per month for the months of October 2009, November 2009 and December 2009.
Patient # 13 was admitted on 8/3/09. His last counseling session was on 12/2/09. He received an average of 1.8 hours of counseling per month for the months of October 2009, November 2009 and December 2009.
Patient # 14 was admitted on 7/15/09. Her last day of counseling was on 12/17/09. She received an average of 1.75 hours of counseling per month for the months of October 2009, November 2009 and December 2009.
Patient # 15 was admitted on 8/9/09. Her last day of counseling was on 12/29/09. She received an average of 1.87 hours of counseling per month for the months of October 2009, November 2009 and December 2009.
The facility director and the clinical supervisor were interviewed on January 12 and January 13, 2010 and confirmed that this has been a problem area. They did provide documentation to demonstrate that progress has been made to correct this issue and that the plan of correction is ongoing.
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Plan of Correction
The Clinical Supervisor will implement weekly reviews of required and provided direct service hours. Compliance will be addressed during weekly clinical team meetings and individual clinical supervision. Action plans will be required when counselors do not provide ample psychotherapy services according to the individual treatment and rehabilitation plan. Timeframe to implement is immediate and ongoing. The Program Director and Clinical Supervisor will be responsible for oversight. |