INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 13 through April 15, 2010 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 and a plan of correction is due on May 11, 2010.
|
Plan of Correction
|
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on review of the documented fire drills and staff interview, the facility failed to document that a fire alarm or smoke detector was activated during each drill.
The findings include:
Based on the review of the fire drill log on April 13, 2010 and a staff interview with the Facility Director, the facility failed to document that the fire alarm or smoke detector was activated during each drill. Additionally, there was no documentation of an approved alternative fire drill procedure.
|
Plan of Correction
The Director sent in an exception request on 4/22/10; waiting on response from state. In the meantime, the facility will document and activate a smoke detector or fire alarm during each drill. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
|
Observations
Based on a review of the 2008 annual report during the onsite licensing inspection of April 13 through April 15, 2010 and an interview with facility staff, the facility failed to document a financial statement of income and expenses in the body of the report
The findings include:
The annual report was reviewed during the licensing inspection. No financial statement of income and expenses was documented. The facility staff confirmed that a statement of income and expenses was not included in the body of the annual report.
|
Plan of Correction
A financial statement of income and expenses generated by the corporate office will be provided as a general statement in the annual report. The director of Discovery House will check the annual report to make sure that the statement of income and expenses is included in the annual report. |
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.
|
Observations
Based on a review of fiscal documents presented at the time of the inspection and interview with facility staff, the facility failed to document an annual audit of financial activities for the year that ended December 31, 2008.
The findings included:
During the onsite licensing inspection conducted from April 13 through 15, 2010, 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. The letter from the accountant stated "...A review consists principally of inquiries of group personnel and individual procedures applied to financial data. It is substantially less in scope than an audit in accordance with auditing standards generally accepted in the United States of America, the objective of which is the expression of an opinion regarding the consolidated financial statements taken as a whole. Accordingly we do not express such an opinion."
The documentation presented failed to meet the requirement for the annual financial audit.
Facility staff was interviewed regarding the documentation and content of the annual audit and confirmed that this was the only fiscal document available for review.
.
|
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 responsible to ensure that this is completed. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
|
Observations
Based on the physical plant tour and an interview with the facility director the project failed to ensure the confidentiality of client identity.
The findings include:
The physical plant tour was conducted on April 13, 2010 at approximately 10:30 AM. During the tour the facility director revealed that the bathroom utilized by clients and staff was also used by the staff from the adjoining business. Also located in the same proximity as the bathroom is a kitchenette, lunch room and conference room that is primarily utilized by the staff of the adjoining business. Throughout the day the staff of the adjoining business were repeatedly observed in this area and had the opportunity to see facility clients. By allowing tenants of the adjoining business access to these areas, the facility failed to ensure that the client's identity remained confidential. The plans that were submitted to this department prior to occupying this location did not indicate that any portion of the Discovery House facility would be shared with tenants from the adjoining business.
On October 22, 2009, prior to the facility's relocation to their present site, floor plans were submitted to the Division by Discovery House staff. These floor plans and subsequent interviews with Discovery House staff failed to identify there would be shared space with any adjoining businesses. In fact, Division staff were specifically informed on October 22, 2009 that Discovery House's office space would not be available to other businesses in the commercial complex. During a physical plant inspection of the current site on the above identified date, Discovery House staff specified that physical plant changes would occur prior to occupation of the facility to ensure that only Discovery House would have accessibility to the building.
An interview with staff on April 13, 2010 revealed that the adjoining business has had ongoing access to the facility through a door equiped with a coded entry. Said entry allows for free access by the adjoining business into the facility. Both security of the methadone and client confidentiality are compromised by this current arrangement.
|
Plan of Correction
The Director of Discovery House spoke with the business owner of the adjoining business on 6/1/10. The business owner agreed to imform his employees by 6/5/10 that they could no longer use the bathroom or break room in the "shared space" from 5-11am Monday through Friday each week. The business owner was also going to inform the other business' employees that they must enter their place of business through their own lobby, not the "shared lobby." The Director of Discovery House will confirm with the business owner that he has indeed delivered this message to the adjoining business' employees by end of business day of 6/5/10. The Director will monitor the shared space and immediately address any adjoining business employees if they enter the shared space during limited access times on an ongoing basis if needed. The long term goal of constructing a patient bathroom in Discovery House's main suite will be pursued pending the Lower Moreland Township's Zoning Board Appeal. The date of action is unknown for the rendering of this decision. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of client records on April 14 through April 15, 2010, and an interview with the facility director, the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment.
The findings include:
Based on a review of twenty-one client records, four records were required to have a notification of termination. The notification of termination was missing in two of four client records reviewed, # 11 and 12.
An interview with the facility director confirmed that notification of termination letters were not sent to clients who were "absent without leave (AWOL)".
|
Plan of Correction
The Clinical Supervisor will conduct an in-service about sending out letters when pts have been absent from tx to notify them that they will be involuntarily terminated due to absence. Both the director and clinical supervisor will conduct a case consultation with the medical director and notify counselors when a patient has been 7 or 30+ days absent from the program and will be involuntarily terminated from the program. The counselor will be asked to complete the termination letter. The clinical supervisor and director will both sign the letter, and give it to the administrative assistant to mail out to the patient. When a patient is discharged, the clinical supervisor will be responsible for doing an audit on that chart before it is closed out completely and filed to ensure that the patient was notified in writing that he or she was being involuntarily terminated from the program. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
|
Observations
Based on a review of client records on April 14 through April 15, 2010, and an interview with the facility director, the facility failed to inform the client that they shall have an opportunity to request reconsideration of the decision to terminate treatment.
The findings include:
Based on a review of twenty-one client records, four records were required to have the opportunity to request reconsideration of the decision to terminate treatment. The notification to request reconsideration to terminate treatment was missing in two of four client records reviewed, # 11 and 12.
An interview with the facility director confirmed that they were not sending termination notification to clients who went AWOL from the program.
|
Plan of Correction
The Clinical Supervisor will conduct an in-service about sending out letters when patients have been absent from treatment to notify them that they will be involuntarily terminated due to absence. The Clinical Supervisor will conduct an in-service about sending out letters when pts have been absent from tx to notify them that they will be involuntarily terminated due to absence. Both the director and clinical supervisor will conduct a case consultation with the medical director and notify counselors when a patient has been 7 or 30+ days absent from the program and will be involuntarily terminated from the program. The counselor will be asked to complete the termination letter. The clinical supervisor and director will both sign the letter, and give it to the administrative assistant to mail out to the patient. When a patient is discharged, the clinical supervisor will be responsible for doing an audit on that chart before it is closed out completely and filed to ensure that the patient was notified in writing that he or she was being involuntarily terminated from the program. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
|
Observations
Based on the review of patient records, the facility failed to restrict the determination of a patient's dose to the physician in one patient record.
In addition, based on a physical plant walk through and observation, the facility failed to restrict those other than patients from the dosing window.
The findings include:
Twenty-one patient records were reviewed on April 14 and 15, 2010. One patient record was reviewed for dose change orders. Patient record # 17 contained documentation by a counselor to increase the patient's dosage by an amount specified in the documentation. Only the physician may make this determination of dose change. The facility failed to restrict the dose determination to the physician.
On April 13, 2010, a physical plant walk through of the dosing area was conducted at about 10:00 - 10:30 AM. During this time frame, it was observed that two patients were at separate dosing windows. One female patient went to the dosing window with an infant in a carrier and the other female patient went to the other window with a toddler. The facility failed to follow their policy that states "Only one patient will be allowed at the dosing window at a time. To maintain safety and allow for the appropriate assessment of each patient, patients will not be allowed to have hats, sunglasses, beverages or children at the dosing window."
|
Plan of Correction
The Clinical Supervisor will conduct an inservice to make sure that counselors know that only the doctor can prescribe and determine dosage levels for patients. The Clinical Supervisor will conduct chart audits on monthly basis to ensure this does not happen again. Also, signs were displayed by the dispensary on 5/1/10 that no children will be allowed at the dispensing window after 5/1/10. Nursing has been informed by the director to enforce this policy. Director and Clinical Supervisor will monitor nursing to ensure that children are not at the dosing window. |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
|
Observations
Based on the review of patient records, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation in one of one patient records.
The findings include:
Twenty-one patient records were reviewed April 14 and 15, 2010. Two patient records were reviewed for involuntary or therapeutic discharge. One of two patient records contained documentation of the patient being discharged for reasons other than those listed by regulation. Client record # 17 was discharged for behavioral reasons according to the administrative discharge list. Documentation in patient record # 17 stated that the patient met with the director on November 18, 2009 to develop a payment plan due to having a balance of over $200 since October 2009. On January 14, 2010, the patient met with the director again to address payment issues. While on site, the patient called a staff member a vulgar name and it was then determined the patient would be placed on an administrative/behavioral withdrawal based on a determination of inappropriate behavior on the part of patient # 17. The facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation in one of two patient records, specifically patient # 17.
|
Plan of Correction
Before a patient is discharged, the medical director, facility director, and clinical supervisor will meet to discuss the reason and appropriateness for involuntary discharge of a patient. The treatment team listed above will also consult with the state and faciilty regulations to avoid discharging a patient for reasons not allowed. |
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.
|
Observations
Based on the review of client records, the facility failed to document support services in five of twenty client records reviewed.
The findings include:
Twenty-one client records were reviewed on April 14 and April 15, 2010. Twenty client records were reviewed for documentation of proposed support services on the client's treatment plan. Client records # 4, 5, 11, 17, and 21 had no documentation of proposed support services in the comprehensive treatment plan.
|
Plan of Correction
An inservice will be conducted by the clinical supervisor to have all counselors include and document support services for their patients in treatment plans. The Clinical Supervisor will check each treatment plan to ensure that support services are documented before approving each plan. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
|
Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to display a telephone number that can be accessed by the general public in case of an emergency.
The findings include:
A physical plant inspection was conducted on April 13, 2010. A telephone number that is conspicuously displayed to the general public is required at all outpatient treatment programs. The facility failed to display an emergency telephone number that was available to the general public. The facility director confirmed that a telephone number was not posted for public view.
|
Plan of Correction
The emergency telephone line was posted by the director on the front door of the facility's suite for emergency purposes on 5/5/10. The director will monitor that this sign is posted each week. If the sign is removed, it will be reposted by the director immediately. |