INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 16-17, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document that each counselor met both the education and experiential qualifications for the position.
Employee #7 was hired as a counselor on February 27, 2022 and did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience required to be a counselor with a bachelor's degree.
Employee #8 was hired as a counselor on September 26, 2022 and did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience required to be a counselor with a bachelor's degree.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
Clinic Director and Clinical Supervisor met on 11/21/22 and discussed counselor assistant responsibilities and supervision of such. Clinic Director and Clinical Supervisor to implement changes to counselor #7's supervision effective 11/22/22. These changes include CD, CS or lead counselor sitting in on one session per week; review of all cases on case load weekly with CS and monthly with CD for the next six months.
CS and CD will meet weekly for supervision and discuss progress of clinician. Clinician will meet with CS weekly for regular supervision and with CD monthly for review of cases.
Counselor #8 has since left the clinic.
Clinic Director and Clinical Supervisor also met with Lead Clinician to enlist her assistance in the supervision requirements as she is also an LPC.
Clinic Director will ensure that all documentation of supervision is completed on a monthly basis. CD will monitor all supervision records via the monthly SCORECARD as well as review of all supervision notes weekly.
Clinic Director will review resumes and experience more closely effective 11/21/22 and will ensure that candidates have the needed clinical experience.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Employee #6 was hired on May 3, 2022 as a counselor and was still in the position as of the date of the inspection. The training was completed on June 28, 2022.
Employee #9 was hired on April 18, 2022 as a counselor and was still in the position as of the date of the inspection. The training was completed on May 2, 2022.
Employee #10 was hired on June 20, 2022 as a counselor and was still in the position as of the date of the inspection. The training was completed on June 28, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
On 11/18/22 Clinic Director and the Health and Safety Liaison reviewed the documentation requirements for staff regarding safety and emergency procedures. Clinic Director and Health and Safety Liaison discussed making sure that emergency safety trainings are completed within the first 3 days of employment. Clinic Director will review hiring dates with Health and Safety Liaison to ensure this occurs.
The Health and Safety manager will review the Health and Safety binder, on a monthly basis, to note and ensure all staff are properly trained and documented accordingly. Clinic director will monitor on a quarterly basis. Clinic director will keep a spreadsheet of employee start dates and when training is due and will inform Health and Safety Liaison on trainings needed for staff.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies.
Employee #6 was hired on May 3, 2022 as a counselor and was still in the position as of the date of the inspection. The training was completed on June 28, 2022.
Employee #9 was hired on April 18, 2022 as a counselor and was still in the position as of the date of the inspection. The training was completed on May 2, 2022.
Employee #10 was hired on June 20, 2022 as a counselor and was still in the position as of the date of the inspection. The training was completed on June 28, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On 11/18/22 Clinic Director and the Health and Safety Liaison reviewed the documentation requirements for staff regarding safety and emergency procedures. Clinic Director and Health and Safety Liaison discussed making sure that emergency safety trainings are completed within the first 3 days of employment. Clinic Director will review hiring dates with Health and Safety Liaison to ensure this occurs.
The Health and Safety manager will review the Health and Safety binder, on a monthly basis, to note and ensure all staff are properly trained and documented accordingly. Clinic director will monitor on a quarterly basis. Clinic director will keep a spreadsheet of employee start dates and when training is due and will inform Health and Safety Liaison on trainings needed for staff.
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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.
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Observations
Based on a review of patient records, the facility failed to obtain a consent to release information form prior to releasing information in one out of eleven records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Patient #8 was admitted on December 10, 2021 and was still active at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the January 13, 2022 licensing inspection.
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Plan of Correction
Plan of Correction:
The Clinic Director will provide a training on completing a release of information correctly to make sure the program is in compliance with this regulation. The training to be conducted on 12/13/22.
The Clinical Supervisor will review releases of information for accuracy and ensure that these releases of information are completed in its entirety during the quality records review process to ensure continued compliance in this area. Regional director will provide a review of §255.5 and 42 CFR along with a trainings surrounding proper completion of ROI's. Currently scheduled for December 13th. Compliance team will provide quarterly follow up reviews to same during Monthly Staff meetings.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of patient records, the facility failed to notify the patient, in writing, of a decision to involuntarily terminate the patient's treatment at the project in two out of two applicable patient record.
Patient #5 was admitted on March 18, 2020 and discharged on March 15, 2022.
Patient #7 was admitted on February 3, 2021 and discharged on May 28, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinic Director, as per Operational protocol, will review any and all recommendations for involuntary transitions from program services with the RD and will ensure final outcomes of such are provided to the patient in written format. The Clinical Supervisor will oversee and monitor same as will the Clinic Director and such will be discussed in supervision and regular monthly staff meetings.
Clinic Director will provide, upon the decision of involuntarily termination, all patients with written notification of such decision with the reason identified. The notification of termination will be documented in the EMR. Termination letter was obtained on 11/22/22 and will be utilized effective 11/22/22 for all involuntary terminations.
Ongoing compliance with this regulation will be monitored utilizing the quality record review process which will be analyzed monthly at the program level by the clinical supervisor and CTC Director.
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715.20 LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
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Observations
Based on a review of patient records, the facility failed to document the notification of the previous narcotic treatment program of the admission and initial dose of the patient in one out of two applicable record.
Patient #10 was admitted on October 10, 2022 and was still active at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
The Clinic Director and Clinical Supervisor will provide a training by 12/27/22 for transfer processes between OTP's for continued maintenance, detoxification or another treatment activity. The training will review the requirement that a transfer acknowledgement form has been documented in the EMR and that the transferring program has been notified of completed transfer.
Monthly reviews of any/all transfer patients either ""IN"" or ""OUT' of Huntingdon Valley CTC will be completed to ensure documented compliance to regulation.
Ongoing compliance with this regulation will be monitored utilizing the quality record review process which will be analyzed monthly at the program level by the clinical supervisor and CTC Director. The Clinical Supervisor will address non-compliance in this area during individual supervision.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to document an annual reevaluation by the narcotic treatment physician within the regulatory timeframe in one out of five applicable records reviewed.
Patient #9 was admitted on September 5, 2018 and was still active at the time of the inspection. An annual physical was due on September 5, 2022; however, it was not completed until September 13, 2022.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the January 13, 2022 licensing inspection.
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Plan of Correction
A mandatory training for all staff will be provided by the Director on 12/13/2022 which will review Annual documentation requirements including that all Annual Medical Assessments are to be scheduled a minimum of two weeks prior to the scheduled due date in the EMR to ensure that completion of the required documentation is timely.
The Clinic Director will review the services due report in the EMR a minimum of once per week with CTC leadership to ensure patients are scheduled for and complete their annual physicals timely. Charge nurse will monitor, weekly, for the completion of annual physical examinations, along with Medical Director.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document an annual clinical evaluation with all areas of regulation addressed within the regulatory timeframe in four out of five applicable records reviewed.
Patient #3 was admitted on July 1, 2019 and was discharged on September 28, 2022. The annual clinical evaluation was due no later than July 1, 2022; however, it was not completed until August 3, 2022.
Patient #4 was admitted on April 17, 2019 and was discharged on July 21, 2022. The annual clinical evaluation was due on no later than April 17, 2022; however, it was not completed until June 28, 2022.
Patient #9 was admitted on September 5, 2018 and was still active at the time of the inspection. The annual clinical evaluation was due no later than September 5, 2022; however, it was not completed until September 9, 2022.
Patient #11 was admitted on April 16, 2014 and was still active at the time of the inspection. The annual clinical evaluation was due no later than April 16, 2022; however, it was not completed until April 22, 2022.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the January 13, 2022 licensing inspection.
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Plan of Correction
A mandatory training for all staff will be provided by the Director on 12/13/2022 which will review Annual documentation requirements including that all Annual Clinical Evaluations are to be scheduled a minimum of two weeks prior to the scheduled due date in the EMR to ensure that completion of the required documentation is timely.
The Clinic Director will review the services due report in the EMR a minimum of once per week with CTC leadership to ensure annual clinical evaluations are completed timely. Charge nurse will monitor, weekly, along with Medical Director to ensure that annual evaluations are completed.
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709.92(a) 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:
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Observations
Based on a review of patient records, the facility failed to document a comprehensive treatment plan within the guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days following admission.
Patient #7 was admitted on September 20, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than October 20, 2022; however, it was not completed until November 1, 2022
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will work with the Clinical Supervisor and team to ensure timely plans are documented to all patient individual treatment plans in accordance to §709.92(b).
During the 12/13/2022 clinical staff meeting, the clinic director and clinical supervisor will review this regulation and require that all counseling staff complete internal audits of patient electronic records using EMR reporting on a weekly basis to ensure services are completed timely.
Clinic Director and Clinical Supervisor will train and re-educate all clinical staff at 12/13/22 staff meeting on completing treatment plans with patients and timelines of paperwork.
The clinical supervisor will monitor and aid with oversight of compliance with this regulation during weekly supervision meetings to ensure tx plans are updated timely; utilizing reports from the CTC's EMR [SMART] to support same. Clinical supervisor will report to Clinic Director the progress of the timeliness of completion of treatment plans by all staff.
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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 patient records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of nine applicable records reviewed.
Patient #1 was admitted on December 3, 2018 and was still active at the time of the inspection. A treatment plan update was completed on June 16, 2022 and the next update was due no later than August 16, 2022; however, the next update was completed on August 30, 2022.
Patient #3 was admitted on July 1, 2019 and discharged September 28, 2022. A treatment plan update was completed on January 3, 2022 and the next update was due no later than March 3, 2022; however, it was completed on June 1, 2022.
Patient #8 was admitted on April 7, 2015 and was still active at the time of the inspection. A treatment plan update was completed on August 1, 2022 and the next update was due no later than October 1, 2022; however, it was completed on October 10, 2022.
Patient #9 was admitted on September 5, 2018 and was still active at the time of the inspection. A treatment plan update was completed on May 10, 2022 and the next update was due no later than July 10, 2022; however, it was not completed until July 14, 2022. Additionally, a treatment plan update was completed on July 14, 2022 and the next update was due no later than September 14, 2022; however, it was not completed until September 30, 2022.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the January 13, 2022 licensing inspection.
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Plan of Correction
The CTC Director will work with the Clinical Supervisor and team to ensure timely updates are documented to all patient individual treatment plans in accordance to §709.92(b).
During the 12/13/2022 clinical staff meeting, the clinic director and clinical supervisor will review this regulation and require that all counseling staff complete internal audits of patient electronic records using EMR reporting on a weekly basis to ensure services are completed timely.
The clinical supervisor will monitor and aid with oversight of compliance with this regulation during weekly supervision meetings to ensure tx plans are updated timely; Counselor daily checklist and reports from the CTC's EMR [SMART] to support same will be monitored daily by both CS and CD. Clinical supervisor will report to Clinic Director the progress of the timeliness of completion of treatment plans by all staff.
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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 patient records, the facility failed to provide a complete patient record, which is to include a discharge summary within 30 days of discharge, per the facility's policy, in two out of two discharged records reviewed.
Patient #4 was admitted on April 12, 2019 and was discharged on July 21, 2022. There was no discharge summary completed.
Patient #7 was admitted on January 3, 2021 and was discharged on May 28, 2022. The discharge summary was completed July 28, 2022.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 13, 2022 licensing inspection.
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Plan of Correction
The Discharge summaries for patient #4 will be completed as of 12/13/2022.
The Clinic Director and Clinical Supervisor will provide staff with training on Discharge documentation requirements on 12/13/2022. The training will address the discharge summary documentation requirements.
Ongoing compliance with this regulation will be monitored utilizing the quality record review process which will be analyzed monthly at the program level by the clinical supervisor and CTC Director. The Clinical Supervisor will address non-compliance in this area during individual supervision.
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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 a review of patient records, the facility failed to provide a complete patient record, which is to include follow-up information in two out of four discharged records reviewed.
Patient #4 was admitted on April 12, 2019 and was discharged on July 21, 2022.
Patient #5 was admitted on March 18, 2020 and was discharged on March 15, 2022.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 13, 2022 licensing inspection.
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Plan of Correction
The Discharge summaries for patient #4 will be completed as of 12/13/2022.
The Clinic Director and Clinical Supervisor will provide staff with training on Discharge documentation requirements on 12/13/2022. The training will address the discharge summary documentation requirements.
Ongoing compliance with this regulation will be monitored utilizing the quality record review process which will be analyzed monthly at the program level by the clinical supervisor and CTC Director. The Clinical Supervisor will address non-compliance in this area during individual supervision.
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