INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 31- April 2, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House , 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 and a plan of correction is due on May 1, 2008.
|
Plan of Correction
|
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
|
Observations
Based on the review of the training records at the time of the onsite licensing inspection of March 31- April 2, 2008, the facility failed to consistently document training evaluation forms in compliance with agency policy five of eight training record reviewed, specifically training records # 2, 3, 4, 7 and 8.
|
Plan of Correction
All associates of Discovery House will present training feed back forms upon their return from training. Clinical Supervisor will be responsible for maintaining the Training binder and will conduct Month Audits to ensure compliance. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
|
Observations
Based on the review of administrative manuals and interviews with facility staff, the facility failed to document an annual report for 2007 in compliance with the written agency policy. Policy stated that the report is to be completed within 90 days of the end of the year. No annual report for 2007 was documented at the time of the licensing inspection.
|
Plan of Correction
Discovery House will make available the Annual Report within 90 days of the end of the year. Project Director to ensure Annual report will be available for all Facilities. |
709.22(e)(1) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(1) Activities and accomplishments of the preceding year.
|
Observations
Based on a review of administrative materials during the onsite licensing inspection held March 21- April 2, 2008, the facility failed to comply with documenting activities and accomplishments in accordance with agency policy. Agency policy required that the report be completed within 90 days of year end.
|
Plan of Correction
Discovery House will make available the Annual Report within 90 days of the end of the year. Project Director to ensure Annual report will be available for all Facilities |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
|
Observations
Based on a review of administrative materials during the onsite licensing inspection held March 21- April 2, 2008, the facility failed to comply with documenting a financial statement of income and expenses in accordance with agency policy. Agency policy required that the report be completed within 90 days of year end.
|
Plan of Correction
Discovery House will make available the Annual Report within 90 days of the end of the year. Project Director to ensure Annual report will be available for all Facilities |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
|
Observations
Based on a review of administrative materials during the onsite licensing inspection held March 21- April 2, 2008, the facility failed to comply with documenting a statement disclosing the names of officers, directors and principal shareholders, where applicable.
in accordance with agency policy. Agency policy required that the report be completed within 90 days of year end.
|
Plan of Correction
Discovery House will make available the Annual Report within 90 days of the end of the year. Project Director to ensure Annual report will be available for all Facilities.
|
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
|
Observations
Based on a review of the agency manual the facility failed to document complete policies and procedures in adherence to the requirements of Chapter 709. 26(a)(12); 709.26(b)(1) and 709.28(a)(1). Appendices in the manual presented for review were incomplete at the time of the inspection.
|
Plan of Correction
Policy and Procedures will be amended to comply with 709.26(a)(12),709.26(b)(1), and 709.28(a)(1). Senior Leaders and Director will be responsible |
709.26(a)(12) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(12) Employe grievances.
|
Observations
Based on the review of the agency manual during the onsite licensing inspection of March 31- April 2, 2008 the agency failed to document a complete grievance policy. The agency policy on grievances addressed a three step process. Steps one and two were clearly stated in the policy manual. Step three, which addressed review of the grievance by the corporate compliance team, was incomplete. The time frames for the employee or the administration to follow were not stated. There was no indication of who had the authority of final resolution of the grievance.
|
Plan of Correction
Policy and Procedures will be amended to comply with 709.26(a)(12) to include time frames and authority of final resolution. Senior Leaders and Director will be responsible. |
709.26(b)(1) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(1) Confidential maintenance of personnel records.
|
Observations
Based on the review of the agency manual at the time of the onsite licensing inspection of March 31- April 2, 2008, the facility failed to document a complete policy addressing confidential maintenance of personnel records. The policy did not address the process of release of employee information.
|
Plan of Correction
Policy and Procedures will be amended to comply with 709.26(b)(1) to include the process of releasing employee information. Senior Leaders will be responsible |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
|
Observations
Based on the review of the personnel records at the time of the onsite licensing inspection of March 31- April 2, 2008, the facility failed to document reference checks for two of two new hires reviewed in the employee record sample, specifically personnel records # 4 and 5. The sample consisted of eight personnel records.
|
Plan of Correction
All new associates will have documented in their employee file a minimum of 2 references before or within their first week of hire. Director will be responsible |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
|
Observations
Based on the review of the employee records at the time of the onsite licensing inspection of March 31- April 2, 2008, the facility failed to document performance evaluations in accordance with agency policy which requires that annual ratings be complete in the first quarter of each year. Three of six applicable personnel records, # 3, 6 and 7, did not have current evaluations.
|
Plan of Correction
All employees of Discovery House will have Annual Evaluations completed within the first quarter of the new year and filed in their personal records. Director will be responsible. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
|
Observations
Based on the review of the agency manual at the time of the onsite licensing inspection of March 31- April 2, 2008, the facility failed to document a confidentiality policy and procedure consistent with 4 Pa. Code subsection 255.5. The policy did not address 4 Pa. Code subsection 255.5 in its entirety. The policy focused only on 255.5(b). Language in the policy failed to clearly distinguish between HIPAA requirements and 42 CFR ( revision 13 modified 11/2006). The same language was noted in the Confidentiality section of the Outpatient Handbook ( Page 13). The manual containing the appendices contained incorrect information under tab "Y" on page 1 which addressed the client's ability to copy their own health care information "..except to the extent that the information contains psychotherapy notes or information compiled for use in a civil, criminal or administrative proceeding or in other limited circumstances". This language suggests that the project staff collect information for use in civil, criminal or administrative proceedings, in violation of 42 CFR Part 2, subpart B, subsection 2.13.
|
Plan of Correction
Policy and Procedures will be amended to comply with 4 Pa. Code 255.5. Senior Leaders will be responsible. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on the review of the client records at the time of the onsite licensing inspection of March 31- April 2, 2008, the facility failed to consistently adhere to limitations on releases of information imposed at 4 Pa. Code subsection 255.5(b). Consents to release information to families or significant others in the event of an emergency identified the information to be released only as "emergency contact" and did not specify what information would be released in an emergency situation. Refer to client records # 4, 6, 7, 8, 9, 10, 11, 12 and 13. Client record # 5 contained a consent to release information form to an insurance company which would permit the release of progress notes, treatment plans and dosing records. The client record sample was thirteen client records.
|
Plan of Correction
An in-service training will be held by the facility Director on how to complete releases and the limitations of releases as it pertains to state regulations. Director and Clinical Supervisor will be responsible |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
|
Observations
Based on the review of the medication inspection logs at the time of the onsite licensing inspection of March 31- April 2, 2008, the facility failed to document monthly inspections in accordance with agency policy. Monthly inspections were not documented for December 2007 or January 2008.
|
Plan of Correction
Medication Inspections will be conducted on a monthly basis and will be filed in the appendices binder. Nurse Manager will be responsible for completing the form and Director will monitor for compliance via quarterly review of the appendices binder. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
Based on the review of the client records at the time of the onsite licensing inspection of March 31- April 2, 2008, the facility failed to document complete medical histories on each client. Family medical history was not addressed in client records # 1, 2, 3, 4, 5, 8, 9 or 12.
|
Plan of Correction
An in-service training will be provided to staff on documenting family medical history via the intake packet. Medical Director will also include Family medical histories during his initial physical. Director will be responsible for compliance via quarterly chart audits. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on the review of the client records at the time of the onsite licensing inspection of March 31- April 2, 2008, the facility failed to document complete personal histories. Family dynamics and interrelationships were not discussed in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13. Employment information addressed only the most current employment but did not include employment histories in client records # 2, 3, 4,5, 6, 11 and 13. The client record sample consisted of thirteen records.
|
Plan of Correction
An in-service training will be provided on completing intake and admission packets which will include personal histories, family dynamics, and interrelationships as well as employment histories. Outside trainings will also be utilized for staff needing additional training. Director will be responsible for overall compliance via quarterly chart audits.
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of the client records at the time of the onsite licensing inspection of March 31- April 2, 2008, the facility failed to document complete psychosocial evaluations. Coping/defense mechanisms were missed in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13. Negative factors impacting treatment were not assessed in records # 7 and 12. Clinical impressions included content which was more historical than evaluative in client records # 2, 4, 7 and 8. There were 13 client records in the sample reviewed.
|
Plan of Correction
An in-service training will be provided on writing interpretive summaries to include coping/defense mechanisms, negative factors impacting treatment, and clinical impressions. Outside trainings will also be utilized for staff needing additional training on writing psychosocial evaluations. Director will be responsible for overall compliance via quarterly chart audits.
|
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.
|
Observations
Based on the review of the client records at the time of the onsite licensing inspection of March 31- April 2, 2008, the facility failed to consistently document the proposed type of support services offered to the client on the treatment plan. Support services were not identified on the treatment plans in five of thirteen client records reviewed, specifically client records # 4, 5, 11, 12 or 13.
|
Plan of Correction
An in-service training will be provided to staff on treatment planning which shall include documentation of support services offered to the client. Clinical Supervisor will be responsible. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
|
Observations
Based on the review of the client records at the time of the onsite licensing inspection of March 31- April 2, 2008, the facility failed to have the physician sign each treatment plan and update for clients who were funded out of MA funding stream monies. Four of four records of MA/Healthchoices funded client records spot checked, did not have Physician signatures on all treatment plans and treatment plan updates as required under 55 Pa. Code Part III, the medical assistance manual. Refer to client records # 3, 6, 7 and 12.
|
Plan of Correction
The medical Director will review and sign all treatment plans upon their completion. Director will monitor this via quarterly chart audits.
|