INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on November 27 through November 29, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House Cu 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, the facility failed to ensure that each counselor met the qualifications for the position in one of four counselor personnel records.
The findings include:
Thirteen personnel records were reviewed on November 27, 2012. Four staff were reviewed for meeting counselor qualifications. The facility failed to ensure that each counselor met the qualifications for the position in personnel record # 10.
Employee # 10 was hired on 7/9/2012 as a counselor. The counselor did not meet the qualifications for the position of counselor based on a Bachelor of Arts degree in Sociology without one year of clinical experience.
This finding was discussed with the facility director and confirmed.
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Plan of Correction
On 12/5/12, the clinical supervisor and the program director met with the counselor and spoke to him regarding the qualifications of being a counselor. Effective 12/5/12 the counselor is a counselor assistant until he meets the 704.12 regulation. Effective immediately all new hires will be reviewed by the clinical supervisor and lead counselor then forwarded to the program director to ensure the new hire meets the qualifications outlined in 704.12. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to document fire extinguisher training upon staff employment in two of seven personnel records.
The findings include:
Thirteen personnel records were reviewed on November 27, 2012. Seven staff were new hires and were reviewed to verify that staff had been instructed in the use of a fire extinguisher upon employment. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records # 10 and 12.
Employee # 10 was hired on 7/9/2012. Fire extinguisher training was due upon hire. The facility documented fire extinguisher training on 7/17/2012.
Employee # 12 was hired on 10/29/2012. Fire extinguisher training was due upon hire. The facility documented fire extinguisher training on 11/29/2012.
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Plan of Correction
A training was held on 12/3/12 with he fire and safety captain explaining the importance of completing fire extinguisher training upon employment. The director will monitor all new hire paper work to ensure they receive fire extinguisher training upon employment. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records, the facility failed to document all personnel were trained to perform assigned tasks during emergencies upon staff employment in two of seven personnel records.
The findings include:
Thirteen personnel records were reviewed on November 27, 2012. Seven employees were newly employed and were reviewed to verify staff had been trained to perform assigned tasks during emergencies upon employment. The facility failed to document the completion of training to perform assigned tasks during emergencies upon staff employment in personnel records # 10 and 12.
Employee # 10 was hired on 7/9/2012. Training to perform assigned tasks during emergencies was due upon hire. The facility documented emergency training on 7/17/2012.
Employee # 12 was hired on 10/29/2012. Training to perform assigned tasks during emergencies was due upon hire. The facility documented emergency training on 11/29/2012.
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Plan of Correction
A training was held on 12/12/12 with the fire and safety captain explaining the importance of training all personal on all shifts to perform assigned tasks during emergencies. The Program director will monitor new employee trainings for compliance. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills were conducted during different times of the day and list evacuation time.
The findings include:
The fire drill record was reviewed on November 28, 2012. Fire drills were reviewed from December 2011 to November 2012. The facility's hours of operation are from 4:30 a.m. until 1:00 p.m. The facility documented a fire drill at 6 a.m. on November 19, 2012. The document was provided after the review of the fire drill record. The facility failed to document drills between the hours of 4:30 a.m.- 8:30 a.m. from December 2011 to October 2012. The facility has hours with personnel and patients on Saturday and Sunday from 6 to 8 a.m. There were no fire drills documented on these days and during these hours from December 2011 to November 2012. The evacuation time was not documented for the May 2012 and the June 2012 fire drills.
The findings were reviewed and confirmed with the facility director.
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Plan of Correction
A training was held on 12/12/12 with the fire and safety captain regarding the importance of conducting fire drills on different days of the week and at different times of the day. The captain will also document the evacuation time. Effective 1/1/2013, fire drills will be done on every shift. The program director will monitor for compliance in this area. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observation and a physical plant inspection, the facility failed to secure discharged client records within locked storage containers.
The findings include:
A physical plant inspection was completed on November 29, 2012, at 8:45 a.m. At the time of the physical plant inspection, the room with the file cabinets of discharged client records was unlocked and the door was ajar. The file cabinets were not locked.
The clinical supervisor confirmed the client records were not secured within a locked storage container.
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Plan of Correction
A team meeting was held on 11/30/12 explaining the importance of confidentiality and keeping all discharge client records locked within a storage container. The management team will sporadically check the door to monitor compliance. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent prior to the administration of a narcotic agent for maintenance treatment.
The findings include:
Eleven patient records were reviewed on November 28-29, 2012. Five patient records were reviewed for the completion of an informed, voluntary written consent prior to the administration of a narcotic agent. The facility failed to document the completion of an informed, voluntary, written consent prior to the administration of a narcotic agent in patient record # 11.
Patient # 11 was admitted into treatment on May 2, 2012. The patient received their initial dose of methadone on May 2, 2012. There was no documentation of an informed, voluntary written consent prior to the administration of a narcotic agent in patient record # 11.
This finding was confirmed by the facility director and was not disputed.
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Plan of Correction
On 12/3/12 a meeting was held with the medical personal the importance of obtaining an informed voluntary written consent prior to the administration of a narcotic agent. Effective immediately,prior to medication the patient the medical personal will check the patient record to make sure there is written consent. The program director will monitor the forms of new admissions for compliance. |
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.
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Observations
Based on a review of the patient records, the facility failed to document a complete personal history in five of five records reviewed.
The findings include:
Eleven patient records were reviewed November 28-29, 2012. Five patient records were reviewed for a personal history that included family, legal, employment/vocation, educational, military and sexual history. Patient records # 5, 6, 9, 10 and 11 lacked detailed personal histories by answering with one or two word answers and documenting a history of the past 30 days.
Patient # 5 was admitted on 8/30/2012 and discharged on 10/9/2012. The facility failed to document a detailed educational history and sexual history.
Patient # 6 was admitted on 4/17/2012 and discharged on 8/9/2012. The facility failed to document family interrelationships, legal history, a detailed employment/vocational history, detailed educational history, military history, and sexual history.
Patient # 9 was admitted on 7/10/2012. The facility failed to document a detailed educational history, and sexual history.
Patient # 10 was admitted on 10/26/2012. The facility failed to document legal history, a detailed educational history, and sexual history.
Patient # 11 was admitted on 5/2/2012. The facility failed to document legal history, a detailed educational history, and sexual history.
The findings were reviewed with the Clinical Supervisor and Facility Director on November 29, 2012 and confirmed.
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Plan of Correction
A training was held on 11/30/12 by the clinical supervisor and lead counselor regarding the importance of providing personal history that includes detailed information in the area of family, legal, employment, vocational, educational, military, recreational, prior treatment, clients perception of drug use , family drug abuse history and sexual history. Effective 12/31/12 there will be a check list included in the intake packet for employees to follow to ensure that personal histories are detailed. Assessments will be checked by the clinical supervisor and lead counselor prior to the counselor signing on them. The clinic director will do sporadic checks to monitor compliance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of patient records, the facility failed to document psychosocial evaluations that were clinically evaluative in three of five records reviewed.
The findings included:
Eleven patient records were reviewed November 28-29, 2012. Five patient records were reviewed for the content of the psychosocial evaluation. Patient records # 6, 10 and 11 failed to include a psychosocial evaluation that included all components and were clinically evaluative.
Patient # 5 was admitted on 8/30/2012 and discharged on 10/9/2012. The facility failed to document a psychosocial evaluation that included the client's problems and needs to be addressed in treatment, coping mechanisms, and the counselor's impressions regarding the patient. The documentation included a repeat of the patient reported information and did not include an evaluation by the clinician for all required components.
Patient # 10 was admitted on 10/26/2012. The facility failed to document a psychosocial evaluation that included the client's problems and needs to be addressed in treatment, the client's assets and strengths, and the negative factors that might inhibit treatment. The documentation included a repeat of the patient reported information and did not include an evaluation by the clinician for all required components.
Patient # 11 was admitted on 5/2/2012. The facility failed to document a psychosocial evaluation that included coping mechanisms. The documentation included a repeat of the patient reported information and did not include an evaluation by the clinician for all required components.
The findings were reviewed with the Clinical Supervisor and Facility Director on November 29, 2012 and confirmed.
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Plan of Correction
A training was held on 11/30/12 by the clinical supervisor and lead counselor regarding the importance of documenting a psychosocial evaluation that included the client's problems and needs to be addressed in treatment, coping mechanisms, and the counselor's impressions regarding the patient psychosocial. The clinical supervisor and the lead counselor will monitor each psychosocial evaluation prior to saving the document complete. The program director will monitor for compliance. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of patient records, the facility failed to document case consultations that included all of the components in one of three records reviewed.
The findings included:
Eleven patient records were reviewed November 28-29, 2012. Three patient records were reviewed for the case consultations.
Patient # 11 was admitted on 5/2/2012. Case consultations were documented for 8/1/2012 and 11/10/2012. The facility failed to document case consultations that included names of persons attending and their disciplines and the disposition of the case.
The findings were reviewed with the Clinical Supervisor and Facility Director on November 28, 2012, and confirmed.
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Plan of Correction
A training was held on 11/30/12 by the clinical supervisor and lead counselor regarding the importance of documenting names of persons attending and their disciplines and the disposition of the case.
The clinical supervisor and lead counselor will monitor the case consults to make sure that all the components are documented in the case consult prior to saving the document complete. The program director will monitor for compliance.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on the review of patient records, the facility failed to document discharge summaries that included all of the components in six of eight records reviewed.
The findings included:
Eleven patient records were reviewed November 28-29, 2012. Eight patient records were reviewed for discharge summaries. Patient records # 1, 4, 5, 6, 7 and 8 did not include medication as a service offered by the facility. As this facility is a narcotic treatment program, the medication is a significant component of the treatment services offered.
The findings were reviewed with the Clinical Supervisor and Facility Director on November 29, 2012 and confirmed.
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Plan of Correction
A training was held on 11/30/12 by the clinical supervisor and lead counselor regarding the importance of documenting that methadone medication as a service offered by the facility. Prior to saving the discharge summary complete the clinical supervisor and lead counselor will check the discharge summary for documentation that the service was provided. The program director will do sporadic checks to monitor compliance. |