INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 28 - 30, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Discovery House CU- 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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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
The facility failed to document a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served and that every effort will be made to hire staff persons representative of that population.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the 2017 licensure inspection.
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Plan of Correction
Facility Director will work with the Regional Director and Corporate HR department to develop a policy that is in compliance with the regulation regarding recruitment and hiring.
This will be done by May 30, 2019.
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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
The facility failed to document that all staff persons received a minimum of 4 hours of TB/STD training.
Staff #6, hired as a counselor on August 21, 2017 was required to complete TB/STD training by August 21, 2018. There was no documentation that staff #6 completed TB/STD training at the time of the inspection, November 28-30, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Within the next 90 days staff #6 will have TB/STD training. This will be provided by CRNP onsite by using the Dept. OF Health Curriculum.
There was a training held on 12/11/18 with the Clinical Supervisor and the Program Director on the importance of making sure that each new employee has the documented mandatory trainings. This will be monitored by the Director on a monthly basis through monthly training audits. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to document a confidentiality policy and procedure which complies with 4 Pa Code 255.5.
The revised policies and procedures were reviewed. In the "Confidentiality of Patient Records" section, it states that information about suspected violations of elder abuse must be reported; however, suspected elder abuse is not an exception to Pa Code 255.5. In addition, the policy states that Federal laws and regulations do not protect information about a crime committed by a patient or any threat to commit such a crime; however, the state regulations do protect this information. Only if the crime is committed on program premises or against program personnel would it allow the information to be released without a valid consent.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical Services Department will revise the policy on Confidentiality of Patient records to bring the policy into conformance with the regulations. Project Management will review Policy revisions with staff in the January 2019 all staff meeting.
Completion Date:
1/31/2019
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document written policies and procedures regarding all of the client rights.
The revisions to the policy and procedures manual and client handbook were reviewed. Neither the policy manual nor the client handbook documented 709.30 -
(1) A client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
and
(3) The project, facility or clinical director may temporarily remove portions of the records prior to inspection by the client if the director determines that the information may be detrimental of presented to the client.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the 2017 licensing inspection.
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Plan of Correction
Clinical Services Department will revise the Client Rights policy and procedure and the Patient Handbook to bring the Policy and Patient Handbook into conformance with the regulations. Project management will review policy and procedure revisions with all staff at the January 2019 staff meeting.
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715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
The facility failed to document in writing that it notified the transferring narcotic treatment program of the client's admission.
Two of the client's reviewed transferred into the facility from other narcotic treatment programs. The receiving facility is required to notify the transferring facility of the client's admission to decrease the chances of duplicate dosing.
Client #2 was admitted to the facility on October 25, 2018. The transfer acknowledgment was not sent until November 5, 2018.
Client #5 was admitted to the facility on July 26, 2018. The transfer acknowledgment was not sent until August 9, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/4/18 there was a meeting held with the clinical department, Clinical Supervisor and Program Manager explaining the importance of sending transfer acknowledgements to the transferring clinic.
Upon admission of each transferring patient coming into the clinic the administrative assistant will document on the front of the chart a "T" which will indicate the patient is a transfer and will need an acknowledgement send. Also, this will be monitored through the daily census calculation done by the Clinical Supervisor. The Programs Manager will do sporadic checks weekly to ensure compliance. |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
The facility failed to develop policies and procedures which limited the reasons for involuntary termination to those conditions permitted by regulation. In addition, the policies and procedures should include providing a detoxification of at least 7 days, except when a patient commits or threatens to commit acts of physical violence.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Services Department will revise the Termination policy to bring the Policy and Procedure in full conformance with the regulations. Project management will review policy and procedure revisions with all staff at the January 2019 staff meeting. |