INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the September 24, 2010 licensure renewal inspection. The follow-up inspection was conducted on April 4, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 May 5, 2011.
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Plan of Correction
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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. |
709.91(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 follow-up inspection, the facility failed to document a complete personal history in five of eight client records.
The findings included:
Thirteen client records were reviewed during the follow-up inspection on April 4, 2011. Eight client records were reviewed for the completion of the client's personal history. 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 facility did not document a complete personal history in client records # 1, 2, 4, 7 and 8,
Client # 1 was admitted on November 4, 2010. The client record failed to include documentation of the client's family and employment histories. 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 worked full time. No work history was documented for actual positions held by the client.
Client # 2 was admitted on December 1, 2010. The client record failed to include documentation of the client's family, legal, employment, military and sexual histories 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 legal history documented that the client was on "unsupervised probation", but no other information was documented. The employment, military and sexual histories were not documented.
Client # 4 was admitted on February 23, 2011. The client record failed to include documentation of the client's employment, military and recreational histories. The employment history indicated only that the client worked full time. No work history was documented for actual positions held by the client. The client's military and recreational histories were not documented.
Client # 7 was admitted on December 16, 2011. The client record failed to include documentation of the client's employment, educational and military histories.
The employment history indicated only that the client has lost jobs due drug and alcohol use. No work history was documented for actual positions held by the client. The client's educational history indicated only that the client had attended 12th grade. No educational history was documented. The client's military history was not documented.
Client # 8 was admitted on January 5, 2011. The client record failed to include documentation of the client's family, legal, employment, educational, military recreational and sexual histories 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 client's employment history stated only that the client was unable to work due to physical/psychiatric reasons. There was no documentation of the actual reasons for the client being unable to work. The client's legal history documented that the client was on "unsupervised probation", but no other information was documented. The client's educational history indicated only that the client had attended 12th grade. No educational history was documented. The client's military, recreational and sexual histories were not documented.
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Plan of Correction
An in-service training will be held with all clinical staff to address the completion of personal history in the client records. This in-service training will include the use of "starter questions", which asks for detailed, specific information from a patient. Each patient's personal history will be as thorough and complete as possible. Clinical Supervisor will conduct the training and will review for compliance. Time of completion will be by May 5, 2011. |
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, the facility failed to document that an individual treatment and rehabilitation plan had been developed with a client per agency policy and procedure in five of eight client records.
The findings include:
Thirteen client records were reviewed during the follow-up on April 4, 2011. Eight clients records required an individual treatment and rehabilitation plan be developed with the client. Per agency policy, the individual treatment and rehabilitation plan is to be completed within 30 days. The facility did not document an individual treatment and rehabilitation plan per agency policy in client records # 2, 4, 5, 6 and 8.
Client # 2 was admitted on December 1, 2010. The comprehensive treatment plan was due to be completed by January 1, 2011. The comprehensive treatment plan was documented on February 8, 2011.
Client # 4 was admitted on February 23, 2011. The comprehensive treatment plan was due to be completed by March 23, 2011. The comprehensive treatment plan was documented on March 29, 2011.
Client # 5 was admitted on March 2, 2011. The comprehensive treatment plan was due to be completed by April 2, 2011. The comprehensive treatment plan had not been completed as of April 4, 2011.
Client # 6 was admitted on February 3, 2011. The comprehensive treatment plan was due to be completed by March 3, 2011. The comprehensive treatment plan was documented on March 11, 2011.
Client # 8 was admitted on January 5, 2011. The comprehensive treatment plan was due to be completed by February 5, 2011 The comprehensive treatment plan was documented on February 24, 2011.
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Plan of Correction
Our electronic system was changed on March, 2011 to place an automatic delay on a patient once the treatment plans are approved by a supervisor to ensure that a patient signs the treatment plan in a timely manner. Treatment plans are being reviewed on a daily basis by a supervisor. Treatment plans are being reviewed in individual supervision with each counselor to ensure that the plans are being completed by the due date. An in-service training will also be held on May 9, which will include a detailed description of comprehensive treatment planning, ensuring that the problem list matches the treatment plan, and that the plans are being completed by the due date. Clinical Supervisor will monitor for compliance. |