INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on December 12-13, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite 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 the inspection:
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Plan of Correction
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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
The facility failed to document a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served and that every effort will be made to hire staff persons representative of that population.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Services Department will revise the recruitment and hiring policy to address the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort will be made to hire staff persons representative of the population served. Program staff will continue to work with Human Resources Business Partner in the recruitment and hiring of appropriate staff for the project.
Completion Date:
1/15/2018
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709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
The facility failed to have written project policies and procedures regarding the utilization of volunteers.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Services Department will revise the Personnel policy to include the utilization of volunteers in the project. Program will review policy revision with all staff in the January all staff meeting.
Completion Date:
1/15/2018
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document written policies and procedures regarding all of the client rights.
The policy and procedures manual and client handbook were reviewed. Neither the policy manual nor the client handbook documented 709.30 (4) Clients have the right to appeal a decision limiting access the their records to the director, (5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, or
(6) Clients have the right to submit rebuttal data or memoranda to their own record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Services Department will revise the Client Rights policy and procedure to include the client's right to appeal a decision limiting access to records to the director; clients having the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records; clients have the right to submit rebuttal data or memoranda to their own record. Program management will review policy and procedure revisions with all staff at the January 2018 staff meeting.
Completion Date:
1/15/2018 |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
The facility failed to have the physician sign a verbal order within three business days of the when the order was given for records reviewed on December 12-13, 2017.
Record # 1 - A Verbal Order was given on December 6, 2017. There was no documentation that the order had been signed by a physcian.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A training was held on 12/14/17 with the medical staff explaining the importance of making sure verbal orders are signed off by the medical director within 24 hours. The nurse manager will review all orders daily to make sure they are signed off in the allotted time frame. The Program Director will do sporadic checks to make sure the verbal orders are signed. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
The facility failed to develop and policies and procedures to respond to the following unusual incidents:
709.34 (a)
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
(b) (5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State confidentiality laws.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Services Department will revise the Unusual Incident policy and procedure to include how the project will report and respond to a significant disruption of services due to a disaster such as fire, storm, flood or other occurrence which closes the facility for more than one day including if the project requires the presence of police, fire, or ambulance personnel on site. Policy and procedure will be revised to ensure that the revised policy and procedure of reporting an unusual incident to an entity is in full compliance with State confidentiality laws. Program management will review policy and procedure revisions with all staff at the January 2018 staff meeting.
Completion Date:
1/15/2018 |
715.20 LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
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Observations
The facility failed to develop complete written transfer policies and procedures.
The policy and procedure manual was reviewed. The policies and procedures did not include that the facility would transfer the patient within 7 days of the request of the patient and 715.20(4).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
715.20(4)
Clinical Services Department will revise the Transfer policy and procedure to include the project will transfer a patient within 7 days of the patients request to be transferred. Program management will review policy and procedure revisions with all staff at the January 2018 staff meeting.
709.20(4)
Clinical Services Department will revise the Transfer policy and procedure to include the project shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic program. Program management will review policy and procedure revisions with all staff at the January 2018 staff meeting.
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715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
The facility failed to develop policies which included 715.21 (1) (iv).
The policy and procedures manual was reviewed. The policy did not include that a patient may be involuntarily discharged if the patient has failed to follow treatment plan objectives.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
715.21(1)(i-iv)
Clinical Services Department will revise the Termination policy and procedure to include a patient may be involuntarily discharged from the project if the patient has failed to follow treatment plan objectives. Program management will review policy and procedure revisions with all staff at the January 2018 staff meeting.
Completion Date:
1/15/2018
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