INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16 through April 18, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House, 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 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on the review of the fire drill record, the facility failed to include the number of persons in the facility at the time of the drill on the record.
The findings include:
The fire drill record was reviewed on April 16, 2013. The fire drill record was reviewed for twelve months. The fire drill record had a space for comments where staff could document the number of persons in the facility at the time of the drill, however, the staff failed to document the number of persons in the facility at the time of the drill in eleven of twelve months reviewed. The form did not prompt the staff person completing the form to enter the specific information .Therefore it was not documented on a consistent basis. The number of persons in the facility at the time of the drill was not documented for April 2012, May 2012, June 2012, July 2012, August 2012, September 2012, October 2012, November 2012, December 2012, February 2013 and March 2013.
This finding was discussed with facility staff and was not disputed.
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Plan of Correction
705.28(d)(4) The number of persons in the facility at the time of a fire drill needs to be included in the drill record. The number of participants is now being added manually to each drill report. The corporate office will add a field for the number of participants to the report form. The Director of Operations is responsible for the revised form. The Facility Director is responsible for assuring that the number of participants is included on each drill report. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documentation, the project failed to develop goals and objectives for the 2013 calendar year.
The findings were:
A review of administrative documents on April 16, 2013 indicated that the annual goals and objectives for the 2013 calendar year were not complete. The three year Strategic Plan that was documented covered a time period of 2009 through 2012.
A discussion with the facility director on April 16, 2014 confirmed that the project's strategic plan has not been distributed to the facility and was due to be presented at the end of April through a webinar.
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Plan of Correction
709.23(b)(1) The company strategic plan was not finalized for 2013. Since the license visit the plan for 2013 through 2016 was distributed on April 25 via webinar and email. The plan for 2013 contains all the required elements including goals, objectives, time frames and assignments, and it is now being implemented by Discovery House Blair County. The Project Director is responsible for developing this plan and the Facility Director is responsible for implementation. |
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 patient records, the facility exceeded 4 Pa. Code, Subsection 255.5(b) in four of twenty records reviewed. The facility exceeded 4 Pa. Code, Subsection 255.5 (a) (6) in one of twenty records reviewed. The facility also failed to identify who a letter was being written to in one record reviewed.
The findings included:
Twenty-two patient records were reviewed February 16 - 18, 2013. Twenty records were reviewed regarding release of information documentation. The facility failed to ensure that an informed and voluntary consent to release information was obtained in one patient record reviewed, # 14. Record # 4 exceeded 4 Pa. Code, Subsection 255.5 (a) (6) to the patient's employer. Additionally, records # 5, 6, 8, and 17 included documentation that exceeded 4 Pa. Code, Subsection 255.5(b).
Patient record # 4 contained a consent to release signed for an employer on 2/1/2013 that permitted the release of current dose and level, lab work results and drug test results. These items exceeded 4 Pa. Code, Subsection 255. (a) (6) for what is permitted to be released to an employer.
Patient record # 5 contained a consent to release for an insurance company signed on 9/14/2012 that permitted the release of medication history, financial information, current dose and level, lab work results, treatment plan, drug test results and discharge summary. These items exceeded 4 Pa. Code, Subsection 255.5(b) for what is permitted to be released to an insurance company.
Patient record # 6 contained a consent to release for an insurance company signed on 12/4/2012 that permitted the release of medication history, financial information, current dose and level, lab work results, treatment plan, drug test results, discharge summary, and intake summary. These items exceeded 4 Pa. Code, Subsection 255.5(b) for what is permitted to be released to an insurance company.
Patient record #8 contained a consent to release for an insurance company signed on 12/11/2012 that permitted the release of medication history, financial information, current dose and level, lab work results, treatment plan, drug test results, discharge summary, and intake summary. These items exceeded 4 Pa. Code, Subsection 255.5(b) for what is permitted to be released to an insurance company.
Patient record # 14 contained a letter written by the narcotic treatment physician on October 23, 2012 "To Whom it May Concern." There was no way to determine to whom the letter was written. Therefore, the licensing staff was unable verify if a consent to release was signed for the unidentified recipient of this letter.
Patient record # 17 contained a consent to release for an insurance company signed on 1/10/2013 that permitted the release of financial information and discharge summary. These items exceeded 4 Pa. Code, Subsection 255.5(b) for what is permitted to be released to an insurance company.
This finding was discussed with the facility director and clinical supervisor and was not disputed.
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Plan of Correction
709.28 (a)(6), (b) and (c) Signed releases exceeded regulations for governmental agencies and workplaces, and in one case it was unclear as to who a letter was released to. Staff was informed of the violations. Immediately following the license visit the Clinical Supervisor and Director began reviewing all releases for accuracy. Initial training is scheduled for May 16, 2013 with follow up training one week later. Additionally appropriate disciplinary action is being utilized with each staff violating these regulations and with any future violations of these regulations. A third party release that limits release to the five items is available and will be used.
The Facility Director is responsible for assuring that confidentiality is protected and releases are completed correctly. The Clinical Supervisor and Senior Counselor will complete consent form audits during May under the direction on the Facility Director.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on the review of patient records, the facility failed to ensure at least monthly random urine drug screens in two of two records reviewed.
The findings include:
Twenty-two patient records were reviewed April 16-18, 2013. Two patient record were reviewed for random monthly urinalysis. Patient record # 9 and 17 failed to include monthly urine drug screen results.
Patient # 9 was admitted on November 2, 2012 and was discharged on March 18, 2013. The facility failed to document a random monthly urine drug screen for January 2013.
Patient # 17 was admitted on May 12, 2010 and discharged on February 25, 2013. The facility failed to document random monthly urine drug screens for October, November and December of 2012. There was a note in the record on December 6, 2012 indicating that the patient was not submitting urine drug screens anymore because they no longer cared. The failure to provide random monthly urine drug screens was not included in the treatment plan.
This finding was confirmed by the facility director and was not disputed.
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Plan of Correction
715.14(a) Random urine drug screens are to be completed at least monthly for each patient.
The corporate office is considering a change in the computerized procedure to include scheduling no random urines on the last day of the month. This will help avoid patient delay into the next month.
The Nurse Manager is running a report the last two days of each month to identify who has not provided a specimen that month. Any patient identified will be scheduled to provide a urine before the month ends.
Treatment plan training held on May 16, 2013, included a segment on the issue of delays or refusals to provide a urine, communications to counselors of incidents in which nurses are unable to obtain a urine and the need to address refusals in the treatment planning process.
The Nurse Manager is responsible for assuring that each patient provides a urine each month. The Facility Director is responsible for the treatment planning training and the Clinical Supervisor is responsible for assuring that counselors include urine sample refusal in treatment planning.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of the patient records, the facility failed to document a complete personal history in fourteen of fourteen records reviewed.
The findings include:
Twenty-two patient records were reviewed April 16 - 18, 2013. Fourteen patient records were reviewed for a personal history that included prior treatment, family, legal, employment/vocation, educational, military, recreational, and sexual history. Patient records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 16, 18 and 19 lacked detailed personal histories. The historical data recorded consisted of one word responses.
Patient # 1 was admitted on 12/7/2012. The facility failed to document a detailed educational history and sexual history.
Patient # 2 was admitted on 12/18/2012. The facility failed to document a detailed employment/vocation history, educational history and sexual history.
Patient # 3 was admitted on 12/26/2012. The facility failed to document a detailed legal history, employment/vocation history, educational history and sexual history.
Patient # 4 was admitted on 1/11/2013. The facility failed to document a detailed legal history, employment/vocation history, educational history and sexual history.
Patient # 5 was admitted on 9/14/2012. The facility failed to document a detailed legal history, employment/vocation history and sexual history.
Patient # 6 was admitted on 12/4/2012. The facility failed to document a detailed legal history, educational history and sexual history.
Patient # 7 was admitted on 12/4/2012. The facility failed to document a detailed educational history and sexual history.
Patient # 8 was admitted on 12/12/12. The facility failed to document a detailed employment/vocation history, educational history, recreational history, and sexual history.
Patient # 9 was admitted on 11/2/2012. The facility failed to document a detailed educational history and sexual history.
Patient # 10 was admitted 12/21/2012. The facility failed to document a detailed employment/vocation history, educational history, and sexual history.
Patient # 11 was admitted on 12/28/2012. The facility failed to document a detailed educational history and sexual history.
Patient # 16 was admitted on 1/11/2013. The facility failed to document a detailed legal history, employment/vocation history, educational history and sexual history.
Patient # 18 was admitted on 1/18/2013. The facility failed to document a detailed legal history, employment/vocation history, educational history and sexual history.
Patient # 19 was admitted on 3/5/2013. The facility failed to document a detailed legal history, employment/vocation history, educational history and sexual history.
The findings were reviewed with the facility director and clinical supervisor and were not disputed.
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Plan of Correction
709.91(b)(3)(iii) Records lacked detailed personal histories. Immediately staff has been instructed to add history details in whatever open fields are available in the form. The corporate office is completing amendments to the history form which will allow for additional history details. Training is to be held for Blair County clinic staff on or before June 14, 2013 concerning these revisions. The corporate Director of Operations is responsible for revisions to the form. The Clinical Supervisor is responsible for follow up assuring comprehensive completion of histories. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of patient records, the facility failed to document psychosocial evaluations that provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in fourteen of fourteen records reviewed.
The findings included:
On April 16-18, 2013, twenty-two patient records were reviewed. Fourteen of the records were reviewed for the content of the psychosocial evaluation. Patient records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 16, 18 and 19 failed to include a psychosocial evaluation that included a composite picture of the client's problems and needs to be addressed in treatment, the patient's assets and strengths, coping mechanisms, support systems, the negative factors that might inhibit treatment, and the counselor's impressions regarding the patient. The documentation included a repeat of the patient reported information and did not include an evaluation by the clinician for all required components.
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Plan of Correction
709.91(b)(6) A composite, clinical impression of each patient at the time of assessment needs to be included as part of the psychosocial evaluation. Training will be held at DHBC and agency wide prior to June 14, 2013, to assure comprehensive clinical summaries. An audit process by the Clinical Supervisor will be established utilizing a check list of needed elements. Several records will be audited for each assessment counselor each month. The Clinical Supervisor is responsible for the training to be completed and for follow up to assure that required improvements are completed. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of patient records, the facility failed to document support services on eight of fourteen individual treatment and rehabilitation plans.
The findings include:
Twenty-two patient records were reviewed on April 16-18, 2013. Fourteen patient records were reviewed for documentation of proposed support services on the patient's individual treatment and rehabilitation plan. Patient records # 2, 3, 6, 7, 8, 11, 18 and 19 had no documentation of proposed support services on the individual treatment and rehabilitation plan.
This finding was reviewed with the clinical supervisor and was not disputed.
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Plan of Correction
709.92(a)(3) Proposed support services are to be included in the patient's treatment plan. Counselors were informed immediately of this violation and training is to be held May 16 and May 23, 2013, to assure counselor changes in the process and content of treatment plans. Listings of support services will be available for patient and counselor reference and use in treatment planning. The Facility Director is responsible for the training, and the Clinical Supervisor is responsible for assuring this deficiency is corrected by the counselors. The Clinical Supervisor will also provide ongoing follow up supervision. |