INITIAL COMMENTS
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This report is a result of an on-site plan of correction follow up inspection conducted on July 28, 2009 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 August 21, 2009.
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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 administrative documents including the individual training plans for staff, the facility failed to include the completion date of the individual training plan and the identified training resources on the individual training plans for the 2009 training year.
The findings include:
The training files for 15 staff were reviewed during the plan of correction follow up inspection conducted on July 28, 2009. Individual training plans were on file in each of those training records. The completion dates for the individual training plans were not documented on 15 of 15 individual training plans. The potential resources for the training listed on the individual training plans was not documented in 15 of 15 training plans reviewed, specifically employee training files 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15.
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Plan of Correction
The Program Director will make an addendum to the training plans documenting the completion dates and the potential resources. The Clinical Supervisor will have the documentated dates of completion and the potential resources listed on each individual training plan upon completion of any new plan. The Program Director will look over the training plans to monito compliance. |
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 the review of the training files of 12 current and former counselors, the facility failed to ensure that each counselor obtained at least 25 training hours for the 2008 training year in one of seven training files where required.
The findings include:
Twelve counselor training files were reviewed during the plan of correction follow up inspection conducted on July 28, 2009. Seven of the counselors had been employed for the entire 2008 training year. One counselor failed to obtain the required 25 training hours for the 2008 training year, training file # 12. This was the same counselor who failed to obtain 25 training hours for the 2007 training year (this counselor had been identified as training file # 7 for the 2007 training year). The facility failed to ensure that all counselors obtained a minimum of 25 training hours per year as indicated in the plan of correction approved by the Department on December 10, 2009 with the compliance date set by the facility at January 31, 2009.
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Plan of Correction
Previous training on this issue has been completed. Further corrective action can not occur with employees that lack the sufficient training hours do to these employees no longer being employed in the program. The Program Director will take additional action through close evaluation of employee records and training plans to ensure that in the future all counselors maintain a minimum of 25 training hours per year as mandated by the Department of Health and licensing regulations. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection during the unannounced licensing inspection of July 28, 2009 , the facility failed to ensure that no space heaters were stored or utilized on the premises.
The findings included:
A plug in type portable space heater was was screwed to the floor in the facility director's office.
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Plan of Correction
Since the inspection of 7/28/09, the Program Director has utilized an outside company to hard wire each individual space heater.
The Program Director will ensure that there are no space heaters stored or utilized on the premises at any given time. |
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 an inspection of the fire drill and disaster drill logs and an interview with the program manager (facility director), the facility failed to document monthly fire drills since the previous licensing inspection.
The findings include:
The facility fire and disaster drill log was reviewed on July 28, 2009 during a plan of correction follow up inspection. There was no documentation of fire drills for the months of December 2008 and January 2009. The plan of correction indicated that compliance would be attained as of December 3, 2008. The plan of correction was approved on December 10, 2008. The program manager (facility director) was informed on July 28, 2009 that there was no documentation of fire drills for December 2008 and January 2009. The program manager was unable to produce copies of those drills during the follow up inspection.
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Plan of Correction
The Program Director and Fire and Safety Captain will hold a meeting to ensure that the required fire drills and the required disaster drills are being done monthly. These will be documentated 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 a review of the most recent edition of the Discovery House policy and procedure manual, which was printed off of the data base by the program manager (facility director) on the day of the plan of correction follow up inspection, some of the required corrections had not been made.
The findings include:
The procedures for the management of personnel records that had previously been located on pages 75 and 76 of the project manual did not address the release of employee records. This had not been corrected in the most recent edition of the manual reviewed on July 28, 2009. This was confirmed with the program manager (facility director) during the plan of correction follow up inspection.
Chapter 3 of the project manual relating to personnel management failed to define the standard work day and the standard work week. There was a reference to the standard work week in the Associate (employee) Handbook, but nothing in regard to the standard work day. The project manual did not contain a reference to either the work week or the work day.
Page 188 of the project manual refers to the HIPAA regulations and is written to imply that these regulations supersede the privacy protections offered to patients in drug and alcohol treatment facilities provided in the federal regulations at 42 CFR Part 2, Subparts A through E and in the state law and regulations at 71 P. S. Subsections 1690.102 through 1690.112; 4 Pa. Code Subsections 255.5(a), 255.5(b), 255.5(c) and 255.5(d) as well as 28 Pa. Code Subsections 709.28(a) through 709.28(d). The policy and procedure fails to recognize and stipulate that any releases that are permitted by the HIPAA regulations but are prohibited by the regulations addressed above, are still prohibited.
Page 190 of the manual includes policy and procedure stating that the project's electronic record keeping system is HIPAA compliant, but fails to state how this system complies with the requirements listed in the federal regulations at 42 CFR Part 2, Subparts A through E and in the state law and regulations at 71 P. S. Subsections 1690.102 through 1690.112; 4 Pa. Code Subsections 255.5(a), 255.5(b), 255.5(c) and 255.5(d) as well as 28 Pa. Code Subsections 709.28(a) through 709.28(d).
Page 189 fails to address confidentiality for minors in treatment here in the Commonwealth of Pennsylvania, specifically failing to address state law at 71 P. S. Subsection 1690.112 and the federal regulations at 42 CFR Part 2, Subpart B, subsection 2.14(b).
The project policy and procedure manual was written for a multi state project. Compliance with Commonwealth of Pennsylvania code requires that some policies and procedure include specific time frames and required actions. Page 21 of the manual addressed the annual staff training plan, but failed to provide a time frame for the completion of that plan. Page 210 of the project manual (formerly page 225) fails to provide a time frame for the completion of treatment plan updates. Commonwealth regulations require that treatment plan updates be completed every 60 days form the initiation of the individualized treatment plan.
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Plan of Correction
It is the sole responsibility of the Program Director to review policy and make the updates to be incompliance with the Dept of Health regulations. The Program Director will be responsible for updating to be in 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 a review of the project policy and procedure manual and an interview with the program manager (facility director), the facility failed to make the necessary corrections inferred by the facility plan of correction which was approved by the Department of Health on December 10, 2008. The facility plan of correction stipulated that the necessary changes would be made by January 31, 2009.
The findings include:
Page 188 of the project manual refers to the HIPAA regulations and is written to imply that these regulations supersede the privacy protections given to patients in drug and alcohol treatment facilities provided in the federal regulations at 42 CFR Part 2, Subparts A through E and in the state law and regulations at 71 P. S. Subsections 1690.102 through 1690.112; 4 Pa. Code Subsections 255.5(a), 255.5(b), 255.5(c) and 255.5(d) as well as 28 Pa. Code Subsections 709.28(a) through 709.28(d). The policy and procedure fails to recognize and stipulate that any releases that are permitted by the HIPAA regulations but are prohibited by the regulations addressed above, are still prohibited.
Page 190 of the manual includes policy and procedure stating that the project's electronic record keeping system is HIPAA compliant, but fails to state how this system complies with the requirements listed in the federal regulations at 42 CFR Part 2, Subparts A through E and in the state law and regulations at 71 P. S. Subsections 1690.102 through 1690.112; 4 Pa. Code Subsections 255.5(a), 255.5(b), 255.5(c) and 255.5(d) as well as 28 Pa. Code Subsections 709.28(a) through 709.28(d).
Page 189 fails to address confidentiality for minors in treatment here in the Commonwealth of Pennsylvania, specifically failing to address state law at 71 P. S. Subsection 1690.112 and the federal regulations at 42 CFR Part 2, Subpart B, subsection 2.14(b).
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Plan of Correction
It is the sole responsibility of the Program Director to review policy and make the updates to be incompliance with the Dept of Health regulations.
Page 188 of Discovery House Policy and Procedure Manual will be amended to to reflect that any releases that are permitted by the HIPAA regulations but are prohibited by the regulations addressed in the non-compliance are still prohibited.
Page 190 of the Discovery House Policy and Procedure Manual will be amended to address with how the system complies with the requirements listed in the regulations at 42 CFR Part 2, Subparts A through E and in the state law and regulations at 71 P. S. Subsections 1690.102 through 1690.112; 4 Pa. Code Subsections 255.5(a), 255.5(b), 255.5(c) and 255.5(d) as well as 28 Pa. Code Subsections 709.28(a) through 709.28(d).
Page 189 of the Discovery House Policy and Procedure Manual will be amended to address confidentiality for minors in treatment here in the Commonwealth of Pennsylvania, specifically failing to address state law at 71 P. S. Subsection 1690.112 and the federal regulations at 42 CFR Part 2, Subpart B, subsection 2.14(b).
The Program Director will be responsible for updating to be in compliance.
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709.28(c) 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 shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records during the onsite plan of correction follow up inspection of July 28, 2009, the facility failed to obtain an informed and voluntary consent for the disclosure of information contained in the patient record.
The findings included:
Four patient records were reviewed during the inspection. Each patient record was required to include documentation of consents to release information which were voluntary and which addressed the disclosure of client identifying information. Consents to release information forms documented in patient records # 1, 2, 3 and 4 contained the following language: " To communicate with and disclose to one another the following information from my record:". The federal confidentiality regulations at 42 CFR Part 2, Subpart A, Subsection 2.2 specifies that client identifying information may be disclosed in accordance with the stipulations set forth in the text of 42 CFR. The limitations on disclosure are specified in the language documented throughout 42 CFR Part 2 and specifically at 42 CFR Part 2, Subpart C, Subsection 2.31. The format for valid consents to release information is provided at 42 CFR Part 2, Subpart C, Subsection 2.31 and in Commonwealth regulations at 28 Pa. Code Subsection 709.28(c). These consent to release information forms do not comply with the format.
The consents to release information forms in each of the patient records referred to above contains the following statement: " I understand that generally Discovery House - Clearfield may not condition my treatment on whether I sign a consent form, but that in certain limited circumstances I may be denied treatment if I do not sign a a consent form." This statement conflicts with the requirement at 28 Pa . Code Subsection 709.28(c) that a consent to release information be " informed and voluntary".
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Plan of Correction
It is the sole responsibility of the Program Director to review policy and make the updates to be in compliance with the Dept of Health regulations. The Program Director will amend the consent to release form to comply with the requirement: 28 Pa . Code Subsection 709.28(c) that a consent to release information be " informed and voluntary". The Director will remove the statement that "I (the patient),may be denied treatment if I do not sign a consent form." in order to be consistent with the requirement. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of patient records during the onsite plan of correction follow up inspection of July 28, 2009, the facility failed to obtain an informed and voluntary consent for the disclosure of information contained in the patient record.
The findings included:
Four patient records were reviewed during the inspection. Each patient record was required to include documentation of consent to release information forms which adhered to the limitations on the release of information imposed at 4 Pa. Code 255.5(b), relating to the disclosure of client identifying information. Two of four patient records reviewed (# 2 & 4) included documentation of consents to release patient identifying information, including the patient's treatment plan, to the Office of Medical Assistance, a third party payer. The release of the treatment plan to a third party payer exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b).
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Plan of Correction
The Clinical Supervisor and Program Director will hold an inservice on the proper documentation to be released to a third party payer. This information will not exceed 4 Pa. Code 255.5(b). The Clinical Supervisor will monitor compliance through chart audits. The Program Director will do sporadic checks to ensure compliance. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of patient records during the onsite plan of correction follow up inspection of July 28, 2009, the facility failed to document on each treatment plan the type and frequency of services offered to the patient.
The findings included:
Four patient records were reviewed during the inspection. Treatment plans in three patient records were reviewed. Treatment plans in patient records # 1, 2, and 3 included documentation of the frequency of services provided, but failed to document the type of service provided, (group, individual ,family,etc.).
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Plan of Correction
The Clinical Supervisor will hold trainings on treatment plans to ensure that the type of service provided,groups,individual,family will be documented in the treatment plan.The clinical supervisor will monitor before signing each treatment plan to ensure the type of service provided is documented. She will also meet with the assigned counselor for the records which were cited and will add a type and frequency of service to each one that was not in compliance at the time of the inspection.The Program Director will do sporadic checks to ensure 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 patient records during the plan of correction follow up inspection of July 28, 2009, the facility failed to document patient related correspondence on each patient.
The findings included:
Four patient records were reviewed during the inspection. The treatment for each patient was funded at some point through Office of Medical Assistance funding stream monies administered through Healthchoices contractors. As stipulated at 4 pa. Code Subsection 255.5(a)(10), the facility was to document copies of the specific information that was released to the funding entity in each patient record. Patient records # 1, 2, 3 and 4 had no such documentation. An interview with the Program Manager (facility director) revealed that the information was sent to the home office for billing purposes and that a hard copy was to remain at the facility . When these records were requested for the patient records reviewed, the facility director indicated that the documentation of these releases had been shredded by an administrative assistant.
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Plan of Correction
The MMR (methadone maintenance reports) containing the information released to the insurance company for authorization of coverage by our 3rd party will be filed in the patient chart for reference. This will be monitored by the Program Director. |