INITIAL COMMENTS
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This report is a result of an off-site investigation conducted on November 28-30, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the off-site investigation, Discovery House PA 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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709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of personnel records, the facility failed to document written job descriptions which included the supervisor's dated signature in two of four personnel records.
The findings include:
Eleven personnel records were reviewed on November 28-30, 2011. Four personnel records pertained to new employees and were reviewed for documentation of a job description. The facility failed to document a job description which included the supervisor's dated signature in personnel records # 5 and 9.
Employee # 5 is a counselor and was hired on September 6, 2011. There was no documentation of a job description which included the supervisor's dated signature in personnel record # 5.
Employee # 9 is a counselor and was hired on October 24, 2011. There was no documentation of a job description which included the supervisor's dated signature in personnel record # 9.
The facility director was interviewed on November 30, 2011 and confirmed the findings.
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Plan of Correction
Job descriptions of every position will be signed by both the associate and the associate's direct supervisor. This will be immediate and on-going. Program Director will monitor for compliance. |
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 a 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 fifteen of fifteen client records.
The findings include:
Twenty-five client records were reviewed on November 28-30, 2011. Fifteen client records were reviewed for documentation of informed and voluntary consents from the client. 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, 3, 4, 5, 9, 10, 11, 12, 13, 14, 15, 16, 18, 19 and 24.
The clinical supervisor was interviewed on November 30, 2011 and confirmed the findings.
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Plan of Correction
A release of information will be obtained from every patient for any organization that information will be released to or obtained from, including the PA Promise Website. This will be immediate and on-going. Program Director will monitor for compliance. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on the review of client records, the facility failed to document medication records which included the dosage and frequency of use in twelve of fifteen client records.
The findings include:
Twenty five client records were reviewed on November 28-30, 2011. Medication records were required in fifteen of the client records. The facility did not document medication records which included the dosage and frequency of use in client records # 1, 2, 5, 6, 9, 10, 11, 12, 13, 15, 16 and 24.
The Nurse Manager was interviewed on November 30, 2011 and confirmed the findings.
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Plan of Correction
Medication dosage and frequency of use will be documented on every patient, when available. This will include any medications that the patient discloses they are using, including over-the-counter medication and controlled-substances. This will be immediate and on-going. Nurse Practitioner will monitor for 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 a review of client records and the review of the facility's policy and procedures manual, the facility failed to document follow-up information according to policy, in five of ten client records.
The findings include:
Twenty five client records were reviewed on November 28-30, 2011. Ten client records were reviewed as discharged clients and required follow-up information. Per policy, follow-ups are to be completed at 14 and 30 days. The follow up information was not completed per policy in client records # 7, 19, 23, 24 and 25.
Client # 7 was admitted on December 9, 2010 and discharged on October 25, 2011. The 14 day follow-up was due by November 8, 2011. Follow-up was completed on November 18, 2011.
Client # 19 was admitted on February 2, 2011 and discharged on August 1, 2011. The 30 day follow-up was due by August 31, 2011. Follow-up was completed on September 14 , 2011.
Client # 23 was admitted on January 31, 2008 and discharged on July 6, 2011. The 14 day follow-up was due by July 20, 2011. Follow-up was completed on July 27, 2011.
Client # 24 was admitted on June 15, 2011 and discharged on August 1, 2011. The 30 day follow-up was due by August 31, 2011. Follow-up was completed on September 6, 2011.
Client # 25 was admitted on September 14, 2005 and discharged on October 25, 2011. The 14 day follow-up was due by November 8, 2011 and the 30 follow-up was due by November 24, 2011. Both follow-ups were completed on November 29, 2011.
The clinical supervisor was interviewed on November 30, 2011 and confirmed the findings.
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Plan of Correction
Follow-ups will be completed at 14 and 30 days for every discharged patient. A training will be held January 9, 2012 to address this issue. Date of expected compliance will begin 01/10/12 and will be on-going. Clinical Supervisor will monitor for compliance. |