INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 12-14, 2008 by staff from the Division of Drug and Alcohol Program Licensure. 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 and a plan of correction is due on is due December 16, 2008.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel and training records the facility did not document an individual training plan for each employee.
The findings include:
Eight employee training and personnel records were reviewed on November 12-14, 2008. No training plan was documented in the Project Director's training record (personnel record #3), for the current training year(2008).
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Plan of Correction
The Program Director will ensure that all employees have a documented training plan each year as specified in 704.11(b)(1) |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel and training records, the facility did not ensure that each employee met the minimum required training hours for each position for the training year which was completed in 2007.
FINDING:
Eight employee training and personnel records were reviewed on November 12-14,2008. Employee record # 7, a counselor, had 23 hours of training documented for the 2007 training year. Counselors are required to obtain 25 hours of training per year.
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Plan of Correction
An inservice will be held by the Program Director to ensure that each employee is aware of the number of training hours required. The Clinical Supervisor will schedule and monitor training hours for each employee. The program Director will monitor to ensure compliance. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of safety manual records on November 12-14, 2008, the facility did not document monthly fire drills as required each month in the past year.
The findings include:
Fire drill documentation for the past 12 months was reviewed. Documentation for five months ( February, April, June, August and September of 2008) did not include fire drills. Other types of disaster drills were documented for the aforementioned months but no fire drill documentation was on file.
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Plan of Correction
The Program Director and Fire and Safety Captain will hold a meeting to ensure that fire drills are held monthly along with disaster drills and are documented in the correct manner. The program Director will do sporadic checks to ensure compliance |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on the review of the agency policy and procedure manual and ten client records, the facility failed to document a complete, accurate manual.
The findings include:
The policy and procedure manual was reviewed along with a second manual which contained appendices to the manual, and ten client records on November 12-14, 2008. The manual was incomplete, incorrect or inaccurate as noted in the following areas:
Pg. 75-76 - These pages addressed procedures for managing personnel records. Procedures do not address the release of employee related information.
Chapter 3, relating to personnel management, did not contain an orientation policy and procedure. The policies did not define the standard work day and week. Reference to the standard work week was noted in an Associate Handbook but the standard work day was not defined.
Page 167 - The facility addressed the topic of referrals and stated that referrals "...Shall be given to every patient regardless of status at the time of discharge...". The policy is not congruent with actual practice nor is it realistic since frequent AWOL's have occurred and AWOL clients are not given referrals upon discharge.
Language which confuses HIPAA and 42 CFR is documented in various places in the manual, ( Pp 31, 188, 204, 221 ). The facility policy and procedure manual cited references as "(HIPAA) 42 CFR" blending and misstating the two distinct regulations.
Pg. 200 - The aftercare plan policy stated that aftercare plans would be developed at the time of admission, but in the review of ten client records there was no documentation of the development of the aftercare plan, therefore the policy is not reflective of actual practice.
Pg. 201 - The policy addressed follow up contacts but failed to identify who was responsible to make contacts, the frequency with which contacts would occur, the method of contacts and where documentation would be maintained.
Pg. 220- The policy stated that, "...The paper copy of the record is the main record...". This statement is inaccurate and does not reflect actual practice. The facility used a paper record which primarily documented all intake information in hard copy . The day to day counseling and client contact documentation occurred in the electronic record. The bulk of documentation kept on any given client was found in the electronic record.
The policies and procedures manual was written for a multi state project, but the specific time frames and required actions for Pennsylvania were not included in the manual. Examples of this may be found on page 71 of the manual which addresses the annual training plan and page 225 which addresses Individual Treatment Plan reviews and Updates. The manual failed to provide a time frame for the completion of the annual overall staff training plan, nor did it address the mandatory time frame of 60 day reviews for treatment plan updates.
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Plan of Correction
The Policy will be reviewed and amended/changed/purged as needed. The Program Director and Ploicy Advisor from Discovery House home office will be responsible. |
709.26(b)(3) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(3) The orientation of new employes.
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Observations
Based on the review of the agency policy and procedure manual, the facility failed to document an orientation policy for new employees.
The findings include:
The agency policy and procedure manual was reviewed on November 12, 2008. The manual did not contain a written policy which addressed the orientation of new employees.
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Plan of Correction
The Policy will be reviewed and amended/changed/purged as needed. The Program Director and Ploicy Advisor from Discovery House home office will be responsible. |
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 the agency policy and procedure manual, the facility failed to document a complete and accurate confidentiality policy and procedure.
The findings include:
The policy and procedure manual was reviewed on November 12, 2008 for compliance with confidentiality law and regulation. Language in the manual is not specific in addressing and separating HIPAA confidentiality requirements,and the federal confidentiality law ( 42 CFR Part 2). Language in the manual references "...( HIPAA) 42 CFR part 2 (June 9, 1987)" in a number of places failing to demonstrate an understanding of the distinct nature of these two sets of law and regulation. The language in the manual omits reference to 4 Pa. Code subsection 255.5 which is mandatory.
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The document entitled " Confidentiality Patient Notice," incorrectly states "... Discovery House can disclose information without your consent to obtain legal or financial services , or to another medical facility to provide health care to you as long as there is a qualified service organization agreement in place." This document also erroneously states "... Under HIPAA you have the right to request restrictions on certain uses of your health information. Discovery House is not required to agree to any restrictions you request ...". This is incorrect under State law at 71 P.S. Subsection 1690.108(b); 4 Pa. Code Subsection 255.5; 28 Pa. Code Subsection 709.28; and federal regulations at 42 CFR Part 2, Subparts A through E.
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Plan of Correction
The Policy will be reviewed and amended/changed/purged as needed. The Program Director and Policy Advisor from Discovery House home office will be responsible. |
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 ten client records, the facility did not document complete personal histories in ten of ten client records.
The findings include:
Ten client records were reviewed on November 12-14, 2008. All were required to have complete, detailed personal histories. Each of the records contained personal histories which were incomplete for the following reasons:
The facility failed to document personal histories which described family history in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10.
The facility failed to document complete employment histories in client records # 1, 3, 5 and 9. The facility documented only the most recent or current employment and did not document employment histories.
The facility failed to document a complete educational history in client records # 1, 4, 5, 9 and 10. There was no documentation of the reasons for clients not completing their high school education.
during the on site licensing inspection of
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Plan of Correction
The Clinical Supervisor will hold trainings to ensure that all pt records contain complete personal histories,complete employment histories and complete educational histories. Trainigs will also be held to ensure explanations are provided as to why the change in their emploment,and educational status. The clinical Supervisor will monito through chart audits to ensure compliance. The Program Director will do sporadic checks to ensure compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of ten client records, the facility failed to document treatment plan updates which addressed stated treatment goals.
The findings include:
Ten client records were reviewed on November 12-14, 2008. Six of ten client records were required to have treatment plan updates. Four of six client records did not address progress on the stated goals of the treatment plan or did not make modifications to the treatment plan based on the client's documented progress or lack of progress in meeting stated treatment goals and objectives.
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Plan of Correction
The Clinical Supervisor will hold an inservice to ensure the clinicians are documenting the progress or lack there of on each patient treatment plan goals.The clinical supervisor will monitor compliance through approving each patient tx plan.The Program Director will do sporadic checks to ensure compliance |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of ten client records, the facility failed to document aftercare plans in compliance with facility policy and procedure on aftercare planning.
The findings include:
Ten client records were reviewed on November 12-14, 2008. Facility policy and procedure dictated that each of the ten client records was required to have an aftercare plan developed at the beginning of treatment. Aftercare plans were not documented in client records # 1, 3, 5 and 6.
The aftercare plans that were documented in client records # 1,4,7,8, 9 and 10 contained goals which were not individualized and did not have timeframes.
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Plan of Correction
The Program Director and Clinical Supervisor will hold an inservice to ensure facility policy is followed regarding aftercareplans being developed at the begining of treatment. The inservice will also include that each indvidual aftercare plan contains individual goals with time frames. The clinical supervisor will monitor compliance through chart audits. The Program Director will do sporadic checks to ensure compliance. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on the agency policy and procedure manual, the facility failed to document a follow up policy which met the requirements of the standard.
The findings include:
The written follow up policy and procedure was reviewed on November 12-14, 2008. The procedure did not identify who, by job title, is responsible to conduct follow up contacts, the method of contact, and when contact s are to be made and where they are to be documented.
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Plan of Correction
The Policy will be reviewed and amended/changed/purged as needed. The Program Director and Ploicy Advisor from Discovery House home office will be responsible. |