INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 24-26, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House 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:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of facility records conducted as part of the presubmission process and during the onsite inspection, the facility failed to ensure that all staff persons received the required communicable disease training within the required time frames.
Staff Person #4 was hired as a counselor on 7/13/2015, but at the time of the onsite inspection, the facility did not have documentation that the staff person had the required 4 hours of TB/STD training.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
0067: Staff Person #4 received the Certificate of Completion for Communicable Diseases: Tuberculosis, Viral Hepatitis, Sexually Transmitted Diseases from The Center for Addiction Studies and Research on January 26, 2017 for 30 education and training clock hours.
The Clinical Supervisor or designee is tasked to ensure all training hours are completed annually while ensuring the TB/STD & HIV/AIDS training hours are completed within the State of PA guidelines.
The Clinical Supervisor or designee will monitor the completion of the State of PA required TB/STD & HIV/AIDS training by reviewing all clinical and non-clinical new hire employee/s record at 9 months of employment to ensure the TB/STD & HIV/AIDS training is completed.
The Facility Director is responsible for ensuring all training hours are completed annually and the State of PA required trainings are completed within the State of PA time frames.
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the facility records conducted as part of the presubmission process and during the onsite inspection, the facility failed to ensure that there was at least one staff person certified in first aid scheduled for all hours of operation.
The facility had no regularly scheduled staff person with documented certification in first aid.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
0069: The Nurse Manager enrolled in a CPR/First Aid/AED Train the Trainer Class at Holy Redeemer Hospital scheduled for March 25, 2017. The Nurse Manager will conduct a staff CPR/First Aid clinic training on Wednesday, April 5, 2017 for staff First Aid and CPR. The Nursing Team, Director, and PA-C will complete their First Aid Certification by March 20, 2017.
The Nurse Manager is responsible for training staff members for CPR & First Aid upon completion of her train the trainer course.
The Director is responsible for ensuring there are staff members certified in First Aid to cover all hours of operation and the Nurse Manager attends the scheduled Train the Trainer course.
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on staff interviews conducted during the onsite inspection, the facility failed to keep the equipment of the facility in good repair.
The facility has an exception to use an alternate means to conduct fire drills instead of setting off the fire alarm. The alternate means the facility normally uses to conduct fire drills is its public announcement system, but the public announcement system is not operational forcing the facility staff to go door to door within the facility to conduct fire drills.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
P179: The Information Technology Team corrected the intercom problem. The intercom system was tested on February 17, 2017 & February 24, 2017. The clinic Health & Safety Captain will test the intercom system monthly and report its malfunctioning to the Director. The Director will sign the Fire Drill Form which will indicate the intercom status. The Director will work with the Information Technology Team if there is a malfunction to immediately correct the issue.
The Safety Captain or designee will conduct a monthly system check and document the test result on the Monthly Fire Drill Report.
The Director is responsible for ensuring the system is working at all times.
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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 facility records conducted as part of the presubmission process, and staff interviews conducted during the onsite inspection, the facility failed to conduct monthly fire drills.
The facility did not conduct fire drills during the months of July, August and November of the year 2016.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
P273: The Health and Safety Captain will conduct a fire drill monthly. The Facility Director will counter sign the document upon the completion of the monthly Fire Drill Report. This process will begin with the March 2017 Fire Drill. The Health and Safety Captain will develop a Fire Drill Calendar and place the calendar in the Health and Safety Binder which is secured in the Health & Safety Captain's office. The Health & Safety Captain or designee is the only person with access to the binder.
The Health and Safety Captain or Committee designee is responsible for conducting the Fire Drill monthly.
The Director is responsible for ensuring the Fire Drill is conducted monthly.
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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 a review of facility records conducted during the onsite inspection the facility failed to update treatment plans at least every 60 days in 4 of 9 patient records reviewed.
Patient #2 was admitted for treatment on 05/09/2016, and was an active patient at the time of the onsite inspection. The patient's individualized treatment plan was completed on 05/20/2016, but the treatment plan was not updated until 08/01/2016.
Patient #4 was admitted for treatment on 01/04/2016, and was discharged on 10/25/2016. The patient's individualized treatment plan was completed on 02/01/2016, and was updated on 03/10/2016, and 05/04/2016, but was not updated again until 08/01/2016.
Patient #6 was admitted for treatment on 09/14/2011, and was discharged 10/18/2016. The patient had a treatment plan update completed 07/14/2016, but the next treatment plan updated was not completed until 09/27/2016.
Patient #10 was admitted for treatment on 08/17/2016, and was an active patient at the time of the onsite inspection. The patient's individualized treatment plan was completed on 09/21/2016, but the treatment plan was not updated until 12/06/2016.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
1883: The Clinical Supervisor or designee will audit the electronic medical record utilizing the Services Due by Type Report (Treatment Plans) 2x's per month to ensure the treatment plans are updated as required by the State of PA Regulations. The Peer Supervision Group will also audit the charts monthly at their meeting to identify compliance issues, if they exist and document deficiency's on the Peer Supervision Form.
The Clinical Supervisor or designee is responsible for conducting the audits and ensuring the Treatment Plans are updated as required by State of PA Regulations.
The Director is responsible for ensuring the audits are done bi-monthly and the treatment plans are updated as required by the State of PA Regulations.
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