INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the November 15 through November 17, 2011 licensure renewal inspection. The follow-up inspection was conducted on May 21, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Discovery House-CU, Inc. was found not to be in compliance with the applicable chapters of 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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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.
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Observations
Based on a review of the 2010 annual report during the onsite licensing inspection of November 15, 2011 through November 17, 2011, 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 on November 15, 2011. No financial statement of income and expenses was included in the provided published report.
This was still out of compliance at the time of the follow-up conducted on May 2, 2011.
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Plan of Correction
In the 2011 report the financial statement of income was included in the published report. Effective in the 2011 report, the financial statement of income and expenses will be included in the published report. The Program Director will be responsible to work and remind Home Office quarterly to see that it is included. As of June 1st, the annual audit is now available. The Annual Report was sent to the Department Of Health on 6/6/12. the Program Director is responsible to work with home office to ensure that the audit is sent to the DOH. |
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 patient records, the facility failed to document all efforts to retain the patient in the program prior to initiating an involuntary termination in one of one patient records.
The findings include:
Twenty-nine patient records were reviewed May 21 through May 23, 2012. Ten patient discharge records were reviewed. One record was reviewed for involuntary discharge.
Patient # 4 was admitted on May 4, 2009 and discharged on March 26, 2012. The discharge summary states, "Patient was placed on a 10 day administrative withdrawal after he was not complying with paying his weekly self pay obligation for several weeks after communicating that there were issues with his unemployment compensation." It also stated, "Patient was having issues with his compliance for not paying on his weekly balance. Patient also had issues with his attendance due to his finances. Patient complied with other aspects of his treatment by attending his individual sessions, assigned groups and displaying appropriate behaviors while here at the clinic." According to the treatment plan update of October 4, 2010, the patient had a new job. The treatment plan update of December 2, 2010, reported the loss of his funding source. A plan of payment for $100 per week was added to the treatment plan on August 4, 2011. On April 13, 2011, the patient's dose was 114 mg. On May 13, 2011, the patient had received bi-weekly take home doses. On August 10, 2011, the patient's dose was 109 mg and a medical note stated, "Patient has requested 5 mg decrease in preparation of leaving treatment." On August 11, 2011, the patient lost his take home schedule due to absences from dosing. On September 23, 2011, the patient received take home medication for Monday, Wednesday and Friday each week. On October 28, 2011, the patient lost the take home medication doses due to a multidisciplinary team meeting and noncompliance with program rules and regulations. On November 2, 2011, the patient signed a form to receive a voluntary medically supervised withdrawal taper. The documentation stated the "patient was given several opportunities to provide payment." An order was documented for a reduction of 11 mg per day for 9 days and the patient was given 99 mg on November 3, 2011. The patient received 89 mg on November 6, 2011. On November 7, 2011, an medical note stated the "patient to start voluntary medically supervised withdrawal. Patient was given several opportunities to provide payment." An order gave the patient 75 mg with a 14 mg decrease per day for 6 days. On November 10, 2011, the patient met with the physician. The patient was at 47 mg on November 9, 2011. The medical note stated the patient "was on medically supervised withdrawal for financial reasons but that is all fixed now so he plans to remain" in treatment with his lower dose. It was identified the patient was sick all day with sweats, chills, nausea, gastrointestinal upset with urges and cravings. It was noted the patient had not used and had not used for 2.5 years since he was in treatment. An order was written to "work with the patient to titrate to a stable dose." The dose was increased to 52 mg on November 10, 2011; 57 mg on November 11, 2011; 62 mg on November 15, 2011; 67 mg on November 17, 2011; and 70 mg on November 19, 2011.
On November 16, 2011, a financial noncompliance note stated the "counselor met with patient to discuss the outstanding balance in his account. Counselor inquired about patient's plan to make payment on his balance. Patient plans to pay $350 on November 23." The counselor assessed the patient "appears to have a plan in place to pay on his balance" with a plan to "make a payment as planned on 11/23." The note on November 18, 2011, was the same documentation as on November 16. On November 23, 2011, a counselor note reported the patient was unable to make payment, would pay on 11/24. On November 28, 2011, a counselor note reported the patient was unable to pay due to the holidays.
The patient received one hour of counseling per month for December (12/28/2011), January (1/30/2012), February (2/22/2012), and March (3/20/2012). Several brief contacts occurred in March 2012 (7, 8, 9, 14, 15, 16, 19, 21, 22, and 23) reviewing the patient's financial status. On March 16, 2012, the patient was notified of treatment termination for noncompliance with his treatment plan goals. The Administrative notification of treatment termination signed by non-medical staff stated "your dose will decrease by 5.0 mg per day until 3/25/2012". On March 17, 2012, an order was written for 5 mg decrease per day from 50 mg. The patient attended daily until the end of the taper on March 25, 2012. All urine results from January 2011 until March 2012 were negative for illicit substances.
This record was discussed with the facility director and confirmed this finding.
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Plan of Correction
Effective immediately, no patient will be involuntarily discharged for financial Issues. There was a meeting held on 5/23/12 by the clinic director, regarding the importance of finding resources for the patient. The Program Director will monitor all discharges. |
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 the patient records, the facility failed to provide a personal history that included detail in the areas of family history, legal history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history and sexual history in eight of ten records.
The findings include:
Twenty-eight patient records were reviewed on May 21 through May 23, 2012. Ten patient records were reviewed for compliance with the documentation of personal histories. Eight records did not document personal histories that included all components of a personal history, specifically, patient records # 8, 11, 12, 17, 22, 23, 24, and 26.
Patient # 8 was admitted January 19, 2012. The personal history failed to include a detailed history in the areas the patient's family history, employment/vocational history, educational history, military history, and sexual history.
Patient # 11 was admitted on January 12, 2012. The personal history failed to include a detailed history in the areas of the patient's family history, employment/vocational history, educational history, and sexual history.
Patient # 12 was admitted on February 1, 2012. The personal history failed to include a detailed history in the areas of the patient's family history, legal history, educational history, and sexual history.
Patient # 17 was admitted on February 8, 2012. The personal history failed to include a detailed history in the areas of the patient's employment/vocational history, educational history, and sexual history.
Patient # 22 was admitted on January 19, 2012. The personal history failed to include a detailed history in the areas of the patient's sexual history.
Patient # 23 was admitted on February 9, 2012. The personal history failed to include a detailed history in the areas of the patient's employment/vocational history, military history, educational history, and sexual history.
Patient # 24 was admitted on February 28, 2012. The personal history failed to include a detailed history in the areas of the patient's educational history and sexual history.
Patient # 26 was admitted on May 8, 2012. The personal history failed to include a complete history in the areas of the patient's employment/vocational history, educational history, and sexual history.
The areas in the personal history were not documented because the form that the facility utilizes for the personal history documentation does not permit for the therapist to elaborate on the patient's educational, employment/vocational history, military history, and sexual history. The answers that are provided are from a drop down box in the computer system. This finding was discussed with the facility director and was not disputed.
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Plan of Correction
A training was held on 5/23/12 by the clinic director and clinical supervisor regarding the importance of providing personal history that includes detailed information in the area of family, legal, employment, vocational, educational, military, recreational, prior treatment, clients perception of drug use , family drug abuse history and sexual history. Effective 5/24/12 there will be a check list included in the intake packet for employees to follow to ensure that personal histories are detailed. Assessments will be checked by the clinical supervisor and lead counselor prior to the counselor signing on them. The clinic director will do sporadic checks to monitor compliance. |
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 the review of client records, the facility failed to document support services in two of seven client records reviewed.
The findings include:
Twenty-nine client records were reviewed on May 21 through May 23, 2012. Seven client records were reviewed for documentation of proposed support services on the client's treatment plan. Client records # 12 and 21 had no documentation of proposed support services on the comprehensive treatment plan.
This is a repeat citation from the November 15 through November 17, 2011 licensing inspection.
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Plan of Correction
There was a meeting held on 5/23/12 by the Clinical supervisor and clinic director regarding support services being apart of the treatment plan. Effective 5/24/12, the treatment plan will have proposed support services and support services in place for each patient in the general box of the treatment plan and in the observation of the treatment plan. This will be monitored by the clinical supervisor and lead counselor prior to approval of the treatment plan. The Program director will do sporadic checks to ensure compliance. |