INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on October 10-12, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on an observation which occurred during the licensing inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
The findings include:
Throughout the course of the inspection, conversations occurring in counseling sessions were overheard by the licensing specialist. During the morning of October 12, 2012, the entire counseling session occurring in the neighboring counseling office was overheard by the licensing specialist.
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Plan of Correction
Appropriate steps will be taken in each office to drown-out any opportunity of overhearing other counseling sessions. Such steps will include playing soft music on a radio, white-noise machines, etc. This will be immediate and on-going. Program Director will monitor for compliance. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in two of three client records.
The findings include:
Twenty one client records were reviewed on October 10-12, 2012. Seven of the client records reviewed were that of discharged clients. Three of the discharged clients were involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client records # 15 and 18.
Client # 15 was admitted into treatment on December 7, 2006 and was involuntarily terminated from the project on April 16, 2012. There was no documentation of written notification provided to the client as of the on-site inspection which was conducted on October 10-12, 2012.
Client # 18 was admitted into treatment on June 1, 2012 and was involuntarily terminated from the project on August 15, 2012. There was no documentation of written notification provided to the client as of the on-site inspection which was conducted on October 10-12, 2012.
The facility director and clinical supervisor were interviewed at various times throughout the licensing inspection. The aforementioned information was confirmed.
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Plan of Correction
An in-service training on involuntary discharges will be held on November 5, 2012. A termination notice will be provided to each patient who is involuntarily terminated from our program. This will be given in person or in the mail, when necessary. This will be immediate and on-going. Clinical Supervisors will monitor for compliance. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in two of three client records.
The findings include:
Seven discharged client records were reviewed on October 10-12, 2012. Three of the discharged clients reviewed were successfully discharged and required and aftercare plan. Client record #19 and 20 did not include documentation of an aftercare plan.
Client #19 was admitted to treatment on August 10, 2010 and successfully discharged on July 23, 2012. There was no documentation of an aftercare plan in client record #19.
Client #20 was admitted to treatment on November 2, 2011 and successfully discharged on March 5, 2012. There was no documentation of an aftercare plan in client record #20.
An interview with the clinical supervisor took place on October 12, 2012 at which time it was confirmed that there was no documentation of an aftercare plan in client record #19 and 20.
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Plan of Correction
An in-service training on Aftercare plans will be held on November 5, 2012. Aftercare plans will be updated as close to a planned discharge date as possible. All other Aftercare plans will be completed yearly as policy states. This will be immediate and ongoing. Clinical Supervisors 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, the facility failed to document follow up information as per agency policy, in four of seven client records.
The findings include:
Seven discharged outpatient client records were reviewed on October 12, 2012. Per agency policy, follow up contact will be completed within 72 hours for terminated clients, 7 days for transferred / referred clients and 14 days and 30 days for all other clients. Follow up was not documented as per agency policy in client records # 15, 17 18 and 20.
Client #15 was admitted to outpatient treatment on December 7, 2006 and terminated from treatment on April 16, 2012. A follow up contact was due to be completed by April 19, 2012. The follow up contact was not completed until April 27, 2012.
Client #17 was admitted to outpatient treatment on November 9, 2011 and terminated from treatment on May 15, 2012. A follow up contact was due to be completed by May 18, 2012. The follow up contact was not completed until May 30, 2012.
Client #18 was admitted to outpatient treatment on June 1, 2012 and terminated from treatment on August 15, 2012. A follow up contact was due to be completed by August 18, 2012. The follow up contact was not completed until August 27, 2012.
Client #20 was admitted to outpatient treatment on November 2, 2011 and discharged from treatment on March 5, 2012. A follow up contact was due to be completed by March 19, 2012. The follow up contact was not completed until March 29, 2012.
The clinical supervisor was interviewed and confirmed the aforementioned information.
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Plan of Correction
An in-service training on follow-up will be held on November 5, 2012. A follow-up notice will be provided to a patient who is involuntarily terminated from our program within 72 hours; a follow-up notice will be provided to transferred patients within 7 days and all other patients will receive this notice 14 days and 30 days from discharge. This will be given in person or in the mail, whichever is appropriate/necessary. This will be immediate and on-going. Clinical Supervisors will monitor for compliance |