INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 10-11, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Discovery House 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records on December 10-11, 2020, the facility failed to document that each counselor met both the education and experiential qualifications for the position.
Employee #5, whom was hired as a counselor on November 2, 2020, did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience required to be a counselor.
Employee #7, whom was hired as a counselor on November 9, 2020, did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience required to be a counselor.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee # 5 and employee # 7 will be reclassified as counselor assistants effectively immediately and their job descriptions will be changed to reflect this. The requirements outlined in section704.9 and 704.10 relating to counselor assistants will be implemented and followed.
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709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records on December 10-11, 2020, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b) for releases of information in client #6.
Client #6 was admitted on October 12, 2020 and was still active at the time of the inspection. A consent to release form was signed and dated on October 12, 2020 to the funding source that allowed for the release of current dose level and drug test results. A second consent to release form dated October 12, 2020 to a government agency allowed for the release of current dose level.
These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the February 2, 2020 licensing inspection.
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Plan of Correction
The clinical supervisor and the clinic director will instruct the staff of the proper procedure to complete the informed and voluntary consent forms contained in the client record, specifically what information can be disclosed. This issue will be addressed at the staff meeting in January 2021. Client #6 will sign the revised forms by January 29, 2021. The clinical supervisor will monitor this during the monthly record review.
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the December 10-11, 2020 review of physician timesheets for the months of August, September, October and November 2020, the facility failed to provide at least one hour of physician time a week, on site for every ten patients during the week of November 15-21, 2020.
During the week of November 15-21, 2020, the patient census was 304. The facility was required to provide at least 30.4 physician hours. There were 13 physician hours documented.
The findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the February 2, 2020 licensing inspection.
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Plan of Correction
The physician will provide the required on-site hours. The physician is responsible for providing 1/3 of the required hours and the physician assistant is responsible for providing the remaining 2/3 of the required hours. This will be reviewed at the January staff meeting. The clinic director is responsible for monitoring and approving the hours spent on-site by the physician assistant this will be implemented immediately and monitored on an on-going basis. |
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 client records on December 10-11, 2020, the facility failed to document an annual clinical evaluation in client record #3.
Client #3 was admitted on June 24, 2014 and was still active at the time of the inspection. The most recent annual evaluation was due no later than June 24, 2020; however, it was not documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the February 6, 2020 licensing inspection.
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Plan of Correction
DHBC counselors will perform an annual evaluation of each patient, the review will be documented in the patients' medical record. The medical director will review, date and sign the evaluation. This issue will be addressed at the staff meeting in January 2021. The clinical supervisor will monitor this during the monthly records review. |