INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 9-10, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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:
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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 personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employee's #5, 6 and 11 received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #5 was hired as a counselor on April 10, 2019 and was due to have the communicable disease trainings no later than April 10, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #6 was hired as a counselor on December 9, 2019 and was due to have the communicable disease trainings no later than December 9, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #11 was hired as a counselor assistant on August 12, 2019 and was due to have the communicable disease trainings no later than August 12, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
These findings were reviewed with facility during the licensing inspection. This is a repeat citation from the November 28-30, 2018 licensing inspection.
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Plan of Correction
Clinical Supervisor and Lead Counselor will assist new employees in scheduling for HIV/AIDS and TB/STD upon their 14 days New Employee Orientation to DHCU. Director will monitor this to assure compliance.
Employee 5, 6, and 11 are now scheduled for HIV/AIDS Training by facility CRNP on 2/11/21 and also for TB/STD Training on 2/18/21. |
705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
A review of the December 2018 through November 2020 fire drill logs was conducted during the onsite inspection. The facility failed to conduct an unannounced drill during November 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon hire of new director, a Health and Safety committee was formed in order to conduct drills in an appropriate time frame. The Health and Safety appointed Chair Person and/or a member of the committee will conduct and document monthly fire drills. This will be monitored and reviewed by Clinic Director on a monthly basis. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records on December 9-10, 2020, the facility failed to document an informed and voluntary consent to release information form. Clients #3, 4 and 12 had consent to release forms that were missing the specific information to be released.
Client #3 was admitted on February 17, 2020 and was still active at the time of the inspection. The consent form was dated February 14, 2020 to a family member.
Client #4 was admitted on May 20, 2019 and discharged on June 20, 2019. The consent form was dated May 23, 2019 to a hospital.
Client #12 was admitted on May 8, 2020 and was still active at the time of the inspection. The consent form was dated May 8, 2020 to a family member.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor and Lead Counselor will provide training to all staff on how to complete releases with the specific information that is allowed to be released on 1/21/21. Clinical Supervisor will monitor this through Clinical Medical Chart Audits and Peer Reviews on a bi-weekly basis. The identified clients with incorrect releases will be corrected by 1/31/21. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a December 9-10, 2020 review of unusual incidents, the facility failed to file a written report to the Department within three business days for incidents involving the death of two patients on December 4, 2020.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
New Clinical Director has received training on how to complete reporting unusual incidents to the state. New director also now has access to the state incident reporting website as of 1/4/21. Clinic Director and/or designee will assure that unusual incidents are reported in 3 business days. |
709.34 (c) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
Based on a December 9-10, 2020 review of unusual incidents, the facility failed to file a written report to the Department within three business days for incidents involving a patient with a positive COVID-19 test result on November 16, 2020.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
New Clinical Director has received training on how to complete incident reports for outbreaks of contagious diseases. CD will report all incident reports as required in a 3 day period as required by the State Regulations. CD will monitor this on a monthly basis. |
715.14(b) LICENSURE Urine testing
(b) A narcotic treatment program shall develop and implement policies and procedures to ensure that urine collected from patients is unadulterated. These policies and procedures shall include random observation which shall be conducted professionally, ethically and in a manner which respects patient privacy.
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Observations
Based on a physical site inspection on December 10, 2020, the facility failed to follow their policy and procedures during collection of urine. The facility's 5.12.1 policy and procedure states the designated staff member will observe universal safety precautions when handling bodily fluids. A staff person was observed not using disposable gloves while handling a urine sample.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing Supervisor, new CD, and/or designee will order disposable gloves on a monthly basis to have available for daily use in handling drug screen specimens. In addition to, hand-sanitizer with an alcohol base is also readily available and kept in close proximity for dispensing nurses to use after handling any bodily fluid specimens given. Nursing Supervisor and CD will monitor this protocol on a daily basis. |
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.
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Observations
Based on a methadone monitoring on December 10, 2020, the facility failed to dispense medication according to the facility's policy and procedure manual. The facility's policy and procedure 6.1.1 states "before leaving the dosing window, the patient is required to speak to the nurse assuring that medication has not been diverted". A patient was observed not speaking prior to leaving the dispensing window.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Nursing Supervisor will review and train dispensing nurses on policy 6.1.1. Nursing Supervisor will thoroughly explain expectations to dispensing nurse to ensure that all patients speak before and after dosing to prevent medication diversion. This training / supervision will be completed by 1/15/21. CD will monitor documentation of all supervision provided by the Nursing Supervisor. |
715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
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Observations
Based upon a December 9-10, 2020 review of grievances submitted by patients, the facility failed to follow their policy and procedures in regard to their grievance process. The facility's policy and procedure 1.2.12 states the Clinical Director will complete a Grievance Resolution form. The facility failed to complete a Grievance Resolution form for grievances submitted on August 11, 2020 and April 23, 2020.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
New Clinic Director has been trained on the policy 1.2.12 Grievance Procedures for Acadia. CD will ensure that a grievance resolution form is completed for each grievance submitted and a copy is provided to the patient with-in a five day period. CD or designee will monitor this process on a monthly basis. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based upon the review of client records on December 9-10, 2020, the facility failed to conduct an annual reevaluation by the narcotic treatment physician in client #5.
Client #5 was admitted on March 23, 2011 and discharged on September 17, 2019. An annual physical examination was due on March 23, 2019 but was not completed until April 5, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Medical Director and CRNP will ensure that all annual physical evaluations are done by the required due date. Nursing Supervisor, CD and Clinical Supervisor will utilize the alert system and place holds on patients 3 weeks in advance, prior to the due date. CD will monitor this the beginning of each month to ensure compliance. |