INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on January 22 - 23, 2015 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 employee training files, the facility failed to provide documentation of HIV/AIDS and TB/STD training in three of four client records.
The findings include:
Four employee training files were reviewed on January 23, 2015. Three employees were required to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training in employee training files, #3, 5 and 6.
Employee # 3 is a counselor and was hired October 28, 2013. TB/STD training was due to be completed no later than October 28, 2014. Employee #3 completed the TB/STD training on December 29, 2014.
Employee # 5 is an administrative assistant and was hired on August 31, 2009. HIV/AIDS and TB/STD was due to be completed no later than August 31, 2011. The facility failed to provide documentation of HIV/AIDS and TB/STD training.
Employee # 6 is security and was hired on December 12, 2011. HIV/AIDS and TB/STD was due to be completed no later than December 12, 2013. The facility failed to provide documentation of HIV/AIDS and TB/STD training.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance on February 5, 2014.
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Plan of Correction
The Clincial Supervisor or desginee will ensure all Counselors complete the HIV/AIDS and TB/STD training within the their first year of employment within 90 days of the approval of this plan of correction.
The Director will ensure all Administrative and Discovery House Security staff will complete their HIV/AIDS and TB/STD training within their second year of employment within 90 days of the approval of this plan of correction.
Each Supervisor is responsible for ensuring all new staff complete their State of PA required training within the timelines outlined by the State.
The Director will randomly audit new and current staff to ensure the training requirements are met.
The Director is responsible for ensuring the HIV/AIDS and TB/STD training is completed within the time frame identified by the State of PA regulations. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's fire drill log and the facility ' s exception request letter, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill log was reviewed covering the period of February 28, 2014 through December 1, 2014. The facility failed to set off a fire alarm or smoke detector during each fire drill. Additionally, the facility had an exception to use an alternate means of announcing fire drills. However, this exception was for the previous address of 329 East County Line Rd., Hatboro PA.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will submit a request for an updated Exception to the State of PA for the use of the clinic intercom system instead of the activation of the fire alarm / smoke detector system for the monthly fire drills. The fire alarm and smoke detector system is located within a multi-tenant building and the alarm and smoke detection system is maintained and controlled by the landlord.
The Director is responsible for drafting and sending the updated Exception request to the State of PA for review and detemination.
The Director will ensure the excpetion is always up-to-date with any change that impacts the Exception.
The Director will submit the updated Exception request within 30-days of the approval of the POC. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document in each patient record the laboratory test results.
The findings include:
Five patient records were reviewed for documentation of laboratory test results, specifically blood test results, on January 23, 2015. The facility failed to document in two of five patient records the laboratory test results in patient records, # 3 and 4.
The findings were reviewed with facility staff during the methadone monitoring inspection.
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Plan of Correction
The Physician Assistant or designee will ensure that each Discovery House patient will receive a blood test and document the laboratory test results.
The Director will randomly audit patient charts to ensure compliance.
This process will begin immediately, February 18, 2015. |
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 client records, the facility failed to document treatment and rehabilitation plan updates at least every 60 days in five of eleven records reviewed.
The findings include:
Eleven client records were reviewed on January 23, 2015. The facility failed to document treatment plan updates every 60 days in five client records, #1, 2, 4, 10 and 11.
Client # 1 was admitted to the program on January 12, 2013. The last two treatment plan updates were reviewed, November 10, 2014 and January 12, 2015. The facility failed to document treatment plan updates at least every 60 days.
Client # 2 was admitted to the program on January 11, 2012 and discharged on May 13, 2014. The last two treatment plan updates were reviewed, February 25, 2014 and April 30, 2014. The facility failed to document treatment plan updates at least every 60 days.
Client # 4 was admitted to the program on October 27, 2014. The last two treatment plan updates were reviewed, November 7, 2014 and January 15, 2015. The facility failed to document treatment plan updates at least every 60 days.
Client # 10 was admitted to the program on January 22, 2001. The last two treatment plan updates were reviewed, November 12, 2014 and January 20, 2015. The facility failed to document treatment plan updates at least every 60 days.
Client # 11 was admitted to the program on August 30, 2010 and discharged on June 27, 2014. The facility documented two treatment plan updates for 2014, January 27, 2014 and May 5, 2014. The facility failed to document treatment plan updates at least every 60 days.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor or designee will ensure that all patients receive rehabilitative plan updates at least every 60 days. The plan will include all appropriate signatures.
The Director is responsible for ensuring the outlined plan is followed and will randomly audit charts to ensure compliance.
This plan is effective immediately. |