INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on December 1 - 2, 2021 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 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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704.11(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
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employee #8 received minimum of six hours of HIV/AIDS training within the regulatory timeframe.
Employee #8 was hired as a counselor on May 20, 2019 and was due to have the communicable disease training no later than May 20, 2020; however, the training was completed on February 18, 2021.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor and Lead Counselor will assist all new employees in scheduling for HIV/AIDS and TB/STD upon their 14 day New Employee Orientation to DHCU. Clinic Director will monitor this to ensure compliance. |
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 a review of patient records, the facility failed to document an annual clinical evaluation in 2021 for one out of six applicable records reviewed.
Patient #10 was admitted on June 25, 2021 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will monitor all Annual Clinical Evaluations to ensure that not only is the service completed in the case history but that the form itself is thoroughly completed. Clinical Supervisor will alert all counseling staff by 01/06/2022 that the Annual Clinical Evaluation Form is to be completed first, before completing the service prompt in the case history.
Pt # 10 Annual Clinical Evaluation Form was completed on 12/09/2021.
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