INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 21-24, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House PA 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 October 22, 2010.
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Plan of Correction
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709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on the review of facility policy and procedure, client records and a discussion with the Facility Director, the facility failed to document a policy and procedure which is consistent with the intent of the regulation at 28 Pa. Code subsection 715.21 - Patient Termination From a Narcotic Treatment Program - in regard to a client being denied treatment due to an inability to pay for the ongoing services.
The findings included:
Facility policy and procedure on page 40 of the facility manual states the following:
Drug-Free Treatment - "The patient will be invoiced prior to the receipt of any service and only for services being provided on that day. Persons who do not pay may not receive services."
The Facility Director stated that the facility has not served Drug Free clients during the past year, and, based on the information presented at annual licensing inspections, the facility has never treated drug free clients even though it is licensed to do so.
There is nothing in the written policy and procedure that indicates this is not to be applied to Narcotic Treatment Program clients. Documentation in the following patient record indicates that this policy has been applied to a Narcotic Treatment Program patient.
Patient record # 1 - The client was admitted on 12/21/2009 and discharged on 03/10/2010. The patient record included documentation that indicated the client was in arrears on payments for $300.00 and was terminated after a medically supervised withdrawal (MSW).
Documentation in the patient record indicated that the staff had met with the client to discuss the issue and that this individual was put on a medically supervised withdrawal for this issue. Client record note #409352 for ID # 2000, was entered on 3/1/10 for a session that occurred on 2/26/10 at 7:47 AM.
Client record note # 409617, entered on 3/5/10 for a session that occurred on 3/1/10 indicated that the client would be continued on an MSW (Medically Supervised Withdrawal) because his balance was not paid.
The Case Consultation note for the session dated 3/1/10, entered on 3/9/10 indicated that the administrative MSW (Medically Supervised Withdrawal) will continue until balance is paid in full.
The facility policy as written did not exclude Narcotic Treatment Program patients from discharge due to non-payment and, based on the documentation in this record, it appeared as if the policy was being applied to Narcotic Treatment Program patients.
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Plan of Correction
We have added language to our Drug Free Protocol Policy that states the current payment policy does not apply to OTP patients to ensure that it is not misinterpreted to mean that MMTP patients could be denied services based on non-payment. This is to ensure that we comply with PA regulation 28 Pa. Code 715.21 (1). This has been replaced in the Electronic Policy Manual. This change took place on 9/30/2010. Program Director will monitor 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 a review of administrative material and an interview with the facility director, the facility failed to document an audit for the 2009 fiscal year.
The findings include:
The facility director was not able to provide a copy of an annual audit for the 2009 fiscal year during the inspection conducted from September 21 through 24, 2010. The facility director confirmed that an audit for the 2009 fiscal year was not available.
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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. Director will monitor for compliance. |
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.
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Observations
Based on the review of facility policy and procedure, the facility failed to document a written procedure which complied with applicable confidentiality regulation and law.
The findings included:
Facility policy and procedure regarding the confidentiality of client identifying information was reviewed on September 21 and 22, 2010. The confidentiality policy and procedure incorrectly stated that information released to judges who imposed sentence on a particular client and probation or parole officers could be made without written client consent. State law at 71 P. S. subsection 1690.108(b) and the Federal confidentiality regulation at 42 CFR Part 2, Subpart C , Subsection 2.35 require that releases of information to elements of the criminal justice system be made only with the written consent of the client. The state law and federal regulations in this instance supersede the state regulation at 4 Pa. Code Subsection 255.5(a). Facility policy must be written to acknowledge this interplay.
The electronic record keeping system software contains a form which is documented in each client record detailing specifics as to how confidentiality issues are handled within the agency . The confidentiality outline documented in this form incorrectly states to the client that "... you have the right to request restrictions on certain uses and disclosures of your health information , Discovery House is not required to agree to any restrictions you request..." The same principle stated above as referenced from 42 CFR Part 2 requires that all releases of client identifying information be made only with the client's consent unless excepted at 42 CFR Part 2 Subparts D & E.
An ongoing dialogue with facility staff including the Facility Director, Clinical Supervisors and counselors occurred throughout the inspection process. Staff were advised of the findings and given the opportunity to challenge them and provide additional documentation.
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Plan of Correction
Discovery House will comply with Federal Regulations, HIPAA and 42 CFR PART 2 (June 9,
1987) and all state regulations governing confidentiality, 71 P. S. § 1690.108; 4 Pa Code §§
255.5 and 255.7 and 28Pa. Code § 709.28. When Federal and state requirements on this
subject differ, Discovery House will subscribe to the regulation that is most protective of the
client's privacy. Any information released about a patient to individuals, organizations,
employers and/or agencies including third party payers and the justice system will be done so
only with written consent of the patient. This was changed in the Electronic Policy Manual. This change was done on 9/30/2010. Program Director will monitor for compliance. |
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.
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Observations
Based on the review of client records, the facility failed to adhere to the limitations for involuntary terminations in one of one patient record reviewed.
The findings included:
Patient record # 1 - The client was admitted on 12/21/2009 and discharged on 03/10/2010. The patient record included documentation that indicated the client was in arrears on payments for $300.00 and was terminated after a medically supervised withdrawal (MSW).
Documentation in the patient record indicated that the staff had met with the client to discuss the issue and that this individual was put on a medically supervised withdrawal for this issue. Client record note #409352 for ID # 2000, was entered on 3/1/10 for a session that occurred on 2/26/10 at 7:47 AM.
Client record note # 409617, entered on 3/5/10 for a session that occurred on 3/1/10 indicated that the client would be continued on an MSW (Medically Supervised Withdrawal) because his balance was not paid.
The Case Consultation note for the session dated 3/1/10, entered on 3/9/10 indicated that the administrative MSW (Medically Supervised Withdrawal) will continue until balance is paid in full.
The discharge summary described the client's clinical behavior as "exemplary", though the reason given for discharge was listed as non compliance with treatment goals and objectives. This is not borne out by the preponderance of documentation described above.
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Plan of Correction
Discovery House conducted an in-service training on medically supervised withdrawals (MSW)on 07/2010. Documentation will include every non-compliance issue that a patient is dealing with, not just financial. Under no circumstance will a patient be terminated strictly for financial reasons. Program Director will monitor for compliance. |
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 the review of client records during the onsite inspection the facility failed to document a complete personal history in 14 of 20 client records.
The findings included:
Twenty (20) client records were reviewed during the onsite inspection from 9/21/10 to 9/24/10. In accordance with facility policy (page 214) each client record is required to include documentation of accurate and up to date information on each client and to ensure that relevant and current clinical and other information of all patients is accurately and completely recorded. In addition personal histories are to be constructed to provide a baseline for the development of an appropriate, individualized treatment plan for each client. The findings from the review of client records completed on September 22 and 23, 2010 are:
Client # 1 was admitted on 12/21/09. The client record failed to include documentation of a family history which addressed the family interrelationships in the family of origin and the current family constellation. The employment "history" indicated only that the client had no skills or interests and that employment had been "on and off". No work history was documented for actual positions held by the client.
Client# 4 was admitted on 4/30/09. The client record failed to include documentation of a family history which addressed the family interrelationships in the family of origin and the current family constellation. The employment "history" indicated only that the client had held only one job with no explanation as to why . No work history was documented
Client # 5 was admitted on 6/23/09. The client record failed to include documentation of a family history which addressed the family interrelationships in the family of origin and the current family constellation.
Client # 6 was admitted on 6/7/10. The client record failed to include documentation of a family history which addressed the family interrelationships in the family of origin and the current family constellation. No documentation of recreational interests was noted in the record.
Client # 7 was admitted on 2/26/10. The client record failed to include documentation of a family history which addressed the family interrelationships in the family of origin and the current family constellation. The employment "history" indicated only that the client was unemployed and receiving benefits with no explanation as to why . No work history was documented.
Client # 8 was admitted on 4/2/10. The client record failed to include documentation of a family history which addressed the family interrelationships in the family of origin and the current family constellation. Comments in the record indicated that the client had a legal history but it was not documented in the record.
Client # 9 was admitted on 2/4/10. The client record failed to include documentation of a family history which addressed the family interrelationships in the family of origin and the current family constellation. The employment "history" indicated only that the client had held only a job as a Certified Nurses Aide with no documentation of a corresponding work history.
Client # 10 was admitted on 2/1/10. The client record included documentation of an incomplete personal history . Missing components of the personal history included: the employment history, educational history, recreational history and sexual history. This client was a transfer from another Discovery House facility and records on file were incomplete.
Client # 11 was admitted on 1/13/10. The client record failed to include documentation of a family history which addressed the family interrelationships in the family of origin and the current family constellation.
Client # 12 was admitted on 8/5/10. The client record failed to include documentation of a family history which addressed the family interrelationships in the family of origin and the current family constellation. The employment "history" indicated only that the client was looking for work . No previous work history was documented.
Client # 13 was admitted on 2/9/10. The client record failed to include documentation of a family history which addressed the family interrelationships in the family of origin and the current family constellation. No work history was documented.
Client # 15 was admitted on 8/11/10. No work history was documented.
Client # 18 was admitted on 6/16/10. No work history was documented.
Client # 20 was admitted on 3/31/10. No work history was documented.
An ongoing dialogue was held with the administrative and supervisory staff throughout the period of the inspection . The staff were given the opportunity provide additional documentation if available over the period of the inspection and again at the time of the exit summary. No additional materials were provided.
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Plan of Correction
Personal Histories will be complete and inclusive in all Psychosocial Evaluations. This will be immediate and on-going. An in-service training on the Psychosocial Evaluation, including, but not limited to, personal history will be completed on 11/01/2010. Clinical Supervisors will monitor for compliance. |
709.92(a) 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:
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Observations
Based on the review of client records and facility policy and procedure, the facility failed to document each treatment plan in the client record within the timeframe specified by facility policy in twelve of twenty client records reviewed.
The findings included:
Written facility policy required that the comprehensive treatment plan be completed within 30 days from admission. Twenty client records were reviewed during the inspection. The treatment plans in the following records were not done in accordance with written facility policy:
Client #1 was admitted on 12/21/09. The comprehensive treatment plan was documented on 1/28/09.
Client # 4 was admitted on 3/23/09. The comprehensive treatment plan was documented on 4/24/09.
Client # 6 was admitted on 6/7/10. The comprehensive treatment plan was documented on 7/8/10.
Client # 8 was admitted on 4/2/10. The comprehensive treatment plan was documented on 5/11/10.
Client # 9 was admitted on 2/4/10. The comprehensive treatment plan was documented on 3/22/10.
Client # 10 was admitted on 2/1/10. The comprehensive treatment plan was documented on 3/11/10.
Client# 11 was admitted on 1/13/10. The comprehensive treatment plan was documented on 2/23/10.
Client # 12 was admitted on 8/5/10. The comprehensive treatment plan was documented on 9/20/10.
Client # 13 was admitted on 2/9/10. The comprehensive treatment plan was documented on 3/22/10.
Client # 14 was admitted on 7/15/10. The comprehensive treatment plan was documented on 9/23/10.
Client # 16 was admitted on 7/26/10. The comprehensive treatment plan was documented on 9/10/10.
Client # 17 was admitted on 3/26/10. The comprehensive treatment plan was documented on 4/29/10.
An ongoing dialogue with facility staff; including the Facility Director, Clinical Supervisors and counselors; occurred throughout the inspection process. Staff were advised of the findings and given the opportunity to challenge them and provide additional documentation.
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Plan of Correction
An in-service training on Treatment Plans was conducted on 10/04/10. All comprehensive treatment plans will be completed within 30 days for new patients. This will be immediate and on-going. Clinical Supervisor will monitor for compliance. |
709.93(a)(7) 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:
(7) Client-related correspondence.
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Observations
Based on the review of client records and a discussion with the facility director, the facility failed to document client related correspondence for each disclosure of information as required at 4 Pa. Code subsection 255.5 (a)(10).
The findings included:
Twenty client records were reviewed during the onsite inspection. The client records were required to include documentation of the correspondence with outside sources. Seven of the twenty client records included documentation of consents to release information forms to a transportation entity for reimbursement of transportation costs to the client, but there was no documentation of the correspondence with the transportation entity.
Client record # 3 - The client was admitted on 4/30/09 and discharged on 9/13/10. A consent to release information form was documented in the client record for the transportation entity, but there was no documentation of the correspondence with that entity as of the time of the record review on 9/22/10.
Client record # 4 - The client was admitted on 3/23/09 and discharged on 8/10/10. A consent to release information form was documented in the record for the transportation entity, but there was no documentation of the information released as of the time of the record review on 9/22/10.
Client record # 6 - The client was admitted on 6/7/10 and last seen on 9/17/10. A consent to release information form was documented in the record for the transportation entity, but there was no documentation of the information released as of the time of the record review on 9/22/10.
Client record # 8 - The client was admitted on 4/2/10 and last seen on 9/22/10. A consent to release information form was documented in the record for the transportation entity, but there was no documentation of the information released as of the time of the record review on 9/22/10.
Client record # 13 - The client was admitted on 2/9/10 and last seen on 9/10/10. A consent to release information form was documented in the record for the transportation entity, but there was no documentation of the information released as of the time of the record review on 9/23/10.
Client record # 14 - The client was admitted on 7/15/10 and last seen on 9/16/10. A consent to release information form was documented in the record for the transportation entity, but there was no documentation of the information released as of the time of the record review on 9/23/10.
Client record # 17 - The client was admitted on 3/26/10 and last seen on 9/22/10. A consent to release information form was documented in the record for the transportation entity, but there was no documentation of the information released as of the time of the record review on 9/23/10.
A discussion was held with the facility director on 9/23/10 about the issue and he acknowledged that disclosures of information are routinely made to the transportation entity. No documentation of any disclosures of information to the transportation entity was noted in 7 of 7 applicable records.
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Plan of Correction
All client-related correspondence will be documented in the patient's electronic chart in the "releases" section using the "disclosures" button. This will be immediate and on-going. An in-service training was conducted on 10/01/2010 on the release and documentation of client-related correspondence. The Clinical Supervisors will monitor for compliance. |