INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 19, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House Harrisburg 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 and a plan of correction is due on April 13, 2010.
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Plan of Correction
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715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
Based on review of administrative documentation and client records reviewed during the complaint investigation and staff interviews, the facility failed to submit documentation of unusual incidents to the Department as required.
The findings include:
Based on the review of the incident reports on March 19, 2010 the facility failed to complete an incident report for a situation that involved law enforcement being summoned to the facility on February 13, 2010 in regards to patients # 1 and 2. The Clinical Supervisor confirmed that there was not an incident report completed for this situation. Additionally, in reviewing incident reports the facility failed to submit an incident report to this department as required for medication errors that occurred on February 19, 2010. It was confirmed by the Clinical Supervisor that this incident was not sent to this office for review. Lastly, it was documented in a progress note dated 3/8/2010 for patient # 4 that a drug transaction took place in the parking lot of the facility. The facility failed to document this incident on an incident report and failed to submit the report to the Department for review.
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Plan of Correction
Training was provided to staff which focused on Discovery House policy and procedure as well as state regulations as it pertains to incident reporting. Training focused on how to complete an incident report and unusual incident report. Training also focused on what types of incidents need reported to the state. Staff was provided with the regulation 715.28(a)(1-10) for reference as well as Discovery House policy. Two samples were completed as a team. The program Director will review incident reports on a daily basis to ensure timely submission to Department of Health. This was completed on March 25th of 2010. Director to be responsible to ensure compliance in this area is maintained. |
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 review of four patient records the facility failed to update the patient's treatment and rehabilitation plan to include new goals and objectives.
The findings include:
Four patient records were reviewed on March 19, 2010. Patient record # 2 failed to update the treatment and rehabilitation plan to include new goals and objectives. The treatment plan update clearly indicated "no changes have been made to the patients treatment plan due to her missing her appointment to review her treatment plan." The facility failed to document an updated that included recent incidents that had been brought to the facility's attention and had led to police involvement due to alleged criminal behavior.
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Plan of Correction
A training will be held by Clinical Supervisor to the clinical team on 4-7-2010. The training will focus on treatment planning and implementing new goals and objectives. The training will also focus on working with the patient on implementing goals and objectives that incorporate any incident or action that could affect a patient's progress in treatment. The clinical Supervisor will review all treatment plans to ensure compliance before approving treatment plans. Program Director and Lead Counselor to review treatment plans quarterly to ensure overall compliance. This will be completed by 4/8/10. |