INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 5-7, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House-NC, 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observation and a physical plant inspection, the facility failed to provide an unobstructed exit from an emergency exit.
The findings include:
A physical plant inspection was conducted on December 6, 2011 at approximately 3:30 P.M. The emergency exit at the rear of the building was found to be taped shut on both the inside and outside of the door. The exit door could not be opened by the licensing inspector.
On December 6, 2011, the facility director confirmed the emergency exit door was taped shut on both the inside and outside. The door could not be opened by the facility director.
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Plan of Correction
All exit signs on the rear exit door have been remove. The Exit sign on the wall has been removed. This door will no longer be a designated exit. This will be monitored by the Program Director. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on the review of personal records, the facility failed to document the results of a reference investigation in one of one personnel record.
The findings include:
Eight personnel records were reviewed on November 5-7, 2011. One personnel record reviewed was a new employee. Reference results were reviewed for this employee. The results of a reference investigation were not documented for employee # 4.
The facility director confirmed the findings during an interview on December 7, 2011.
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Plan of Correction
All employees upon hire will have references. References will be documented in personal record, if unable to contact given references there will be written documentaion of the attempts date and time in personal records.This will be monitored by the Program Director. |
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, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in eleven of eleven client records.
The findings include:
Twenty three client records were reviewed on December 5-7, 2011. Eleven client records were reviewed for compliance with the requirement to obtain an informed and voluntary consent to release information from the client record. Twelve client records contained consents to release information from a timeframe outside of the current licensing inspection. The facility accessed the Internet site of a funding entity to confirm the client's current insurance coverage. Prior to releasing client information to this funding entity, the facility failed to document an informed and voluntary consent to release information from the client in client records # 1, 4, 6, 9, 10, 11, 12, 14, 15, 16 and 17.
The facility director confirmed the findings during an interview on December 7, 2011.
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Plan of Correction
All local medidcal assstant rleases will be updated to include Deptment of Welfare.Local county medical assistance caseworker and Promise Website for internet access when checking for eligility of insurance via website. Training of staff will be held on 12/22/2011 during staff meeting. Staff will be instructed to have releases signed by patient. The Clinical Supervisor will be responsible for overseeing the completion of releases. |
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 client records, the facility failed to document an aftercare plan, per agency policy, in nine of twenty one client records.
The findings include:
Twenty three client records were reviewed on December 5-7, 2011. Twenty one client records required an aftercare plan. Per facility policy, aftercare plans are to be completed within 14 days of admission. The facility did not document an aftercare plan per facility policy in client records # 1, 3, 5, 6, 9, 12, 14, 15 and 17.
Client # 1 was admitted on August 22, 2011. The aftercare plan was to be completed by September 5, 2011. The aftercare plan was completed on September 27, 2011.
Client # 3 was admitted on November 8, 2011. The aftercare plan was to be completed by November 22, 2011. The aftercare plan was completed on November 30, 2011.
Client # 5 was admitted on November 7, 2011. The aftercare plan was to be completed by November 21, 2011. The aftercare plan was completed on November 30, 2011.
Client # 6 was admitted on November 2, 2011. The aftercare plan was to be completed by November 16, 2011. The aftercare plan was completed on November 29, 2011.
Client # 9 was admitted on August 12, 2011. The aftercare plan was to be completed by August 26, 2011. The aftercare plan was completed on August 31, 2011.
Client # 12 was admitted on October 28, 2011. The aftercare plan was to be completed by November 11, 2011. The aftercare plan was completed on November 14, 2011.
Client # 14 was admitted on October 7, 2011. The aftercare plan was to be completed by October 21, 2011. The aftercare plan was completed on October 24, 2011.
Client # 15 was admitted on April 22, 2011. The aftercare plan was to be completed by May 6 , 2011. The aftercare plan was completed on May 25, 2011.
Client # 17 was admitted on April 8, 2011. The aftercare plan was to be completed by April 22 , 2011. The aftercare plan was completed on April 28, 2011.
The facility director confirmed the findings during an interview on December 7, 2011.
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Plan of Correction
The clinical supervisor will conduct and inservice training on 1/10/2012 in regards to policy on the aftercare plan and timeframes for completion.The Clinical Supervisor will conduct chart audit to monitor compliance. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary within one week of discharge in four of nine client records.
The findings include:
Twenty three client records were reviewed on December 5-7, 2011. Nine client records were reviewed as discharged records and required a discharge summary. Discharge summaries are due within one week of discharge. The facility did not document a discharge summary within one week of discharge in client records # 2, 7, 8 and 22.
Client # 2 was admitted on October 17, 2008 and was discharged on May 20, 2011. The discharge summary was due May 27, 2011. The discharge summary was completed on May 31, 2011.
Client # 7 was admitted on August 20, 2010 and was discharged on June 10, 2011. The discharge summary was due June 17, 2011. The discharge summary was completed on June 30, 2011.
Client # 8 was admitted on August 20, 2010 and was discharged on October 14, 2011. The discharge summary was due October 21, 2011. The discharge summary was completed on October 31, 2011.
Client # 22 was admitted on March 18, 2011 and was discharged on November 26, 2011. The discharge summary was due December 3, 2011. The discharge summary had not been completed as of December 6, 2011.
The facility director confirmed the findings during an interview on December 7, 2011.
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Plan of Correction
The Clinical Supervisor will hold an inservice training on 1/31/2012 on the proper documentation of the discharge summary and time frame of one week of discharge. The Clinical Supervisor will do periodic chart audits to monitor compliance. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information per facility policy, in six of eight client records.
The findings include:
Twenty three client records were reviewed on December 5-7, 2011. Eight client records were reviewed as discharged records and required follow-up. Per facility policy, follow-up is to be completed at 14 and 30 days after discharge. The facility did not document follow-up per policy, in client records # 2, 7, 8, 20, 21 and 23.
Client # 2 was admitted on October 17, 2008 and was discharged on May 20, 2011. The 14 day follow-up was due June 4, 2011. Follow-up was completed on June 9, 2011.
Client # 7 was admitted on August 20, 2010 and was discharged on June 10, 2011. The 14 day follow-up was due June 24, 2011. Follow-up was completed on June 28, 2011.
Client # 8 was admitted on August 20, 2010 and was discharged on October 14, 2011. The 14 day follow-up was due October 28, 2011 and the 30 day follow-up was due November 14, 2011. Follow-ups were completed on October 31 and November 21, 2011.
Client # 20 was admitted on December 12, 2009 and was discharged on November 13, 2011. The 14 day follow-up was due November 27, 2011. There was no 14 day follow-up documented.
Client # 21 was admitted on November 6, 2010 and was discharged on August 5, 2011. The 14 day follow-up was due August 19, 2011 and the 30 day follow-up was due September 4, 2011. Follow-ups were completed on August 22 and September 12, 2011.
Client # 23 was admitted on March 3, 2011 and was discharged on October 14, 2011. The 14 day follow-up was due October 28, 2011 and the 30 day follow-up was due November 13, 2011. There were no follow-ups documented.
The facility director confirmed the findings during an interview on December 7, 2011.
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Plan of Correction
The Clinical Supervisor will hold an inservice training 12/22/2011 concerning the regulation and facility policy requiring follow up contacts to be completed at 14 and 30 day intervals after discharge. The training will address the requirements and documentation. The Clinical Supervisor will do periodic chart audits to monitor compliance. |