INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 15 &16, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health-PA d/b/a Discovery House-PA 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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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate the bathroom by exhaust fan or window. The bathroom located next to the dispensing area did not have a window and the exhaust fan was not operable.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
We will hire a handyman to replace the fan in the 2nd bathroom by 1/31/2023.
Director will follow up on this and call places for handman services for quotes.
Health and Safety Team will inspect quarterly along with the drills to ensure fans in bathrooms are working properly. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form in one out of five applicable records reviewed.
Client #9 was admitted on May 6, 2022 and was still active at the time of the inspection. There was documentation in the case record that on August 4, 2022, the facility mailed a letter to a government agency; however, there was not a signed informed and voluntary consent form documented in the record for the government agency.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Confidentiality was discussed in our Team Meeting on 12/7/22 including what information can be disclosed and to always ensure there is a valid active release before releasing any kind of information verbally or in writing. Clinical Supervisor will discuss in individual supervision with counselors. It was addressed in supervision with the one counselor that had this record on 11/17/22. New staff will attend Confidentiality trainings within their first year. Clinical Supervisor will review for compliance in chart audits. |
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 review of physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients.
During the week of June 19-25, 2022, the patient census was 402. The facility was required to provide at least 40.2 physician hours. There were only 28.25 physician hours documented.
During the week of June 26-July 2, 2022, the patient census was 402. The facility was required to provide at least 40.2 physician hours. There were only 36.25 physician hours documented.
During the week of July 3-9, 2022, the patient census was 400. The facility was required to provide at least 40 physician hours. There were only 36.50 physician hours documented.
During the week of July 31-August 6, 2022, the patient census was 397. The facility was required to provide at least 39.7 physician hours. There were only 35.25 physician hours documented.
During the week of September 4-10, 2022, the patient census was 392. The facility was required to provide at least 39.2 physician hours. There were only 35.25 physician hours documented.
During the week of September 25-October 1, 2022, the patient census was 393. The facility was required to provide at least 39.3 physician hours. There were only 37.50 physician hours documented.
This is a repeat citation from the March 11, 2022 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director will continue to make a medical calendar to ensure medical hours match up with census weekly. We will utilize on call medical as needed to ensure hours are accounted for.
We will hire a full time Nurse Practitioner by 1/31/23 and along with our Medical Director will provide over the required hours for our census weekly. We will utilize our other Medical Director and part time Nurse Practitioner when there is vacation and utilize requests as needed by the State. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to document transfer of patient files to the patient's new treatment facility in one out of one applicable record.
Patient #5 was admitted on October 4, 2021 and transferred to another treatment facility on November 8, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director announced this in our Team meeting on 12/7/22 with all staff to ensure that we sent out information to another facility if pt signs a release. Clinical Supervisor and Director will follow up with counselors prior to pts leaving and ensure appropriate paperwork is being faxed to the receiving clinic. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to complete an annual physical examination given by the narcotic treatment physician which includes an annual reevaluation by the narcotic treatment physician in two out of four applicable records.
Patient #5 was admitted on October 4, 2021 and discharged on November 8, 2022. The annual physical examination was due no later than October 3, 2022; however, it was not documented until October 26, 2022.
Patient #8 was admitted on May 22, 2018 and discharged on June 15, 2022. An annual physical examination was due no later than May 21, 2022; however, there was no documentation in the patient record that one was completed.
This is a repeat citation from the March 11, 2022 licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
We will work on scheduling pts before their admission date, will work with admin and new Nurse Practitioner scheduling before admission date. Director and Clinical Supervisor will review in monthly chart audits to ensure physicals are completed.
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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 the review of patient records, the facility failed to document an annual clinical evaluation with all areas of regulation addressed within the regulatory timeframe in four out of four applicable records reviewed.
Patient #3 was admitted on January 29, 2019 and was still active at the time of the inspection. The annual clinical evaluation completed on January 29, 2022 did not include the medical director ' s signature.
Patient #4 was admitted on January 10, 1995 and was still active at the time of the inspection. The annual clinical evaluation was due no later than January 9, 2022; however, it was not documented until January 26, 2022 and did not include the medical director ' s signature.
Patient #5 was admitted on October 4, 2021 and was discharged on November 8, 2022. The annual clinical evaluation was due no later than October 3, 2022; however, it was not documented until October 7, 2022, and did not include the medical director ' s signature.
Patient # 8 was admitted on May 22, 2018 and discharged on June 15, 2022. The annual clinical evaluation was due no later than May 21, 2022; however, there was no documentation in the patient record that one was completed.
This is a repeat citation from the March 11, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We reviewed the annual clinical dates in our Team Meeting on 12/7/22.
Starting in January 2023 We will ensure that appointments are scheduled for yearly services prior to their admission date, if pts need to reschedule we can complete the annual clinical eval by their admission date w/o the pt and Medical Director will sign the next day. Clinical Supervisor will monitor for compliance in supervision and monthly chart audits. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to develop a comprehensive treatment and rehabilitation plan with the client within their policy ' s set time frame of 8-30 days of admission in four out of five applicable records.
Client #1 was admitted on April 19, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than May 19, 2022; however, it was not completed until May 22, 2022.
Client #2 was admitted on July 22, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than August 22, 2022; however, it was not completed until September 1, 2022.
Client #6 was admitted on September 26, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than October 26, 2022; however, it was not completed until November 10, 2022.
Client #7 was admitted on June 22, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than July 22, 2022; however, it was not completed until July 29, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We reviewed the TX plans and completing the tx plans by the due date on 12/7/22. We were short staffed clinically during 2022 and hired a lot of new staff and this is a training that will be discussed weekly in supervision with Clinical Supervisor. Starting in January 2023 We will ensure that appointments are scheduled for services prior to their admission date, if pts need to reschedule we can complete the tx plan by their admission date w/o the pt and Medical Director will sign once approved by Clinical Supervisor. Clinical Supervisor will monitor for compliance in supervision and monthly chart audits to ensure tx plan are completed prior to admission date.
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