INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on October 27-29, 2014 by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Discovery House HA was found not to be in compliance with the applicable chapters of 4 PA Code and 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to ensure that exits from the facility were unobstructed.
The findings include:
A physical plant inspection was conducted with the facility director on October 28, 2014 at around 11:35 AM. During the inspection it was found that the exit from the building which discharges onto Cameron Street had two chairs in between the doors leading from the vestibule to the interior of the building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chairs Have been removed from the vestibule and a visual inspection of this area has been added to the health and Safety Monthly Checklist to ensure compliance in the future. Program Manger will be responsible. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of outpatient maintenance client records, the facility failed to document treatment plans to include the type and frequency of treatment services in six of ten records reviewed.
The findings include:
Sixteen outpatient maintenance client records were reviewed. Ten of those client records were reviewed for comprehensive treatment plans, which included the type and frequency of treatment services on October 28-29, 2014. Six out of ten outpatient maintenance client records lacked documentation of a treatment plan that included the type and frequency of treatment services, specifically client records 4, 5, 6, 8, 10, and 15.
The comprehensive treatment plan for client #4 was documented on July 8, 2014; however it did not include a proposed type of treatment services for client #4.
The comprehensive treatment plan for client #5 was documented on September 6, 2014; however it did not include a proposed type of treatment services for client #5.
The comprehensive treatment plan for client #6 was documented on August 18, 2014; however it did not include a proposed type or frequency of treatment services for client #6.
The comprehensive treatment plan for client #8 was documented on August 28, 2014; however it did not include a proposed type of treatment services for client #8.
The comprehensive treatment plan for client #10 was documented on May 23, 2014; however it did not include a proposed type of treatment services for client #10.
The comprehensive treatment plan for client #15 was documented on June 26, 2014; however it did not include a proposed type or frequency of treatment services for client #15.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director provided a training to clinical staff on 11/03/14 addressing Type and frequency of services and how to document them in the treatment plan. Clinical supervisors to monitor via tx plan review before signing off on them. This will take place effective 11/03/2014. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of outpatient maintenance client records, the facility failed to document treatment plans to include proposed types of supportive services in four of ten records reviewed.
The findings include:
Sixteen outpatient maintenance client records were reviewed. Ten of those client records were reviewed for comprehensive treatment plans, which included support services on October 28-29, 2014. Four out of ten outpatient maintenance client records lacked documentation of a treatment plan that included a proposed type of support service, specifically client records 4, 5, 8, and 15.
The comprehensive treatment plan for client #4 was documented on August 18, 2014; however it did not include a proposed type of support service for client #4.
The comprehensive treatment plan for client #5 was documented on September 6, 2014; however it did not include a proposed type of support service for client #5.
The comprehensive treatment plan for client #8 was documented on August 28, 2014; however it did not include a proposed type of support service for client #8.
The comprehensive treatment plan for client #15 was documented on June 26, 2014; however it did not include a proposed type of support service for client #15.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director provided a training on 11/03/14 addressing support services and documentation of supportive services in the treatment plan. Clinical staff will document supportive services in dimension review on all future treatment plan. Clinical supervisor will monitor for compliance before signing off on the treatment plan. This has taken effect 11/03/14. |