INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 13-15, 2016, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House HA 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:
|
Plan of Correction
|
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based on an examination for the fire extinguisher tags and staff interviews conducted during the onsite inspection, the facility failed to ensure that all of the fire extinguishers in the facility were inspected at least once a year.
The inspection tags for all of the fire extinguishers in the facility including the extinguisher right next to the facility director's office and the fire extinguisher right outside of the staff bathroom were all marked as last inspected in March of 2015.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
The fire extinguishers have been inspected 12/19/2016 by the fire extinguisher company to be found operable. The fire extinguisher tags have been updated. The fire extinguisher company has been scheduled for inspection on a yearly basis. The Health and Safety Checklist will include inspection updates of fire extinguishers to ensure compliance in the future.
Completion Date: 12/19/2016 |
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.
|
Observations
The facility failed to ensure that all new staff persons received the required fire extinguisher training.
Staff Person #6 was hired on 9/26/2016, but the facility did not have documentation that the staff person received training in the use of fire extinguishers.
Staff Person #7 was hired on 10/10/2016, but the facility did not have documentation that the staff person received training in the use of fire extinguishers.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
Fire extinguisher training checklist has been added for new staff employees. An employee signature acknowledgement 16.1 Health & Safety , v. 16.1 form has been established and an employment checklist will be completed on the first day of employment by the Program Director or other appropriate CTC Division staff. The Program Director will review the checklist for compliancy quarterly.
Staff #6 and staff #7 have attended the the health & safety training on the use of fire extinguishers 12/19/2016 and has signed off on having received the training.
Completion Date: 12/19/2016 |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
The facility failed to conduct unannounced fire drills in the months of February 2016 and July 2016.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
The Health and Safety Captain checklist has been implemented for conducting monthly fire drills to ensure all required documentation is included within the fire drill records. The Health and Safety Captain will conduct-unannounced fire drills every month and document accordingly. The Program Director and/or Health and Safety Team will review the checklist to ensure compliance on a quarterly basis.
Completion Date: 12/19/2016 |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
The facility failed to include all of the required documentation in its fire drill records.
The fire drill log for the fire drill conducted on 01/08/2016 did not document the evacuation routes used or the evacuation time of the drill.
The fire drill log for the fire drill conducted on 03/18/2016, 04/25/2016, and 6/25/2016 did not document the evacuation routes used in the drill.
The fire drill log for the fire drill conducted on 08/12/2016 did not document the evacuation routes used, the evacuation time, or the number of people evacuated in the drill.
The fire drill log for the fire drill conducted on 09/22/2016 and 10/12/2016 did not document the evacuation routes used in the drill.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
The Health and Safety Captain checklist has been implemented for conducting monthly fire drills to ensure all required documentation is included within the fire drill records. The fire drill records will include the date, time, evacuation time, exit route used, number of persons in the facility at the time of drill, problems encountered, and whether the smoke detector or fire alarm was operative. The fire drill will be reviewed monthly by Health and Safety Captain and submitted to Program Director to ensure compliance quarterly.
Completion Date: 12/19/2016 |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
|
Observations
Based on a review of patient records conducted during the onsite inspection, the facility failed to document all of the required information during the screening process in 3 of 8 records reviewed during the onsite inspection.
Patient #2 was admitted for narcotic treatment on 02/29/2016. The facility did not have documentation verifying the patient's identity.
Patient #4 was admitted for narcotic treatment on 01/27/2016. The facility did not have documentation of an emergency contact person for the patient.
Patient #13 was admitted for narcotic treatment on 07/26/2016. The facility did not have documentation of an emergency contact person for the patient.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
Program Director provided a training to clinical staff on 1/5/17 addressing the appropriate screening to determine eligibility for admission. The verification process will include the individual's identity, including name, address, date of birth, emergency contact, and other identifying data. This will take place effective 1/5/17. The Clinical Supervisor will monitor admission process to assure accuracy before individual is admitted into program quarterly.
Completion Date: 1/6/17 |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
|
Observations
Based on staff interviews and a review of patient records conducted during the onsite inspection, the facility failed to provide a complete initial and monthly drug screening urinalysis in buprenorphine patient records, # 10, 11, 12 and 13. The facility completes rapid screen dipstick urine tests and does not send the results to the lab. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
The medical staff at this facility will complete all urine drug screening and send to an approved laboratory for testing and receiving results. This will include initial and monthly drug screening urinalysis in the bupernorphine program.
Plan of Correction: 12/17/2016 |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
The facility failed to provide the required individual psychotherapy hours in 2 of 10 patient records reviewed during the onsite inspection.
Patient #10 was admitted for narcotic treatment on 03/08/2016. The patient received 0 hours of individual psychotherapy in the months of July, August, September and October of the year 2016.
Patient #13 was admitted for narcotic treatment on 07/26/2016. The patient received 0 hours of individual psychotherapy in the months of September and October of the year 2016.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
Program Director provided a training to clinical staff on 1/10/2017 addressing the requirements for individualized psychotherapy services. The requirements would consist of 2.5 hours of psychotherapy per month during the patient's first 2 years, 1 hour of individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing patient assessments. The effective date is 1/10/17. The Program Director and Clinical Supervisor will review for compliance quarterly.
Completion Date: 1/10/17 |
715.23(b)(25) LICENSURE Patient records
(b) Each patient file shall include the following information:
(25) Documentation of patient grievances.
|
Observations
Based on staff interviews and a review of the facility records during the onsite inspection, the facility does not document patient grievances.
The last documented patient grievance was dated 08/05/2015.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
The Program Director has developed a Grievance Binder to store all patient grievances. All patients will continue to have access to grievance forms located at the reception desk. There is a secured mailbox in which the patient grievances will be placed upon completion. The Program Director will check the mail box daily and address any grievances within 24 hours of receiving them.
Completion Date: 12/19/2016 |
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.
|
Observations
The facility failed to ensure that all of the annual evaluations for patients were signed by the medical director.
Patient #8's annual evaluation dated 02/16/2016 was signed by a narcotic treatment physician, but the physician was not the facility's medical director.
Patient #9's annual evaluation dated 08/12/2016 was signed by a narcotic treatment physician, but the physician was not the facility's medical director.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
Program Director provided a training to the medical staff on 1/6/17 addressing the annual evaluations for patients to ensure the understanding of the need for the Medical Director to be the only person who has the authority to sign the annual evaluations for patients. The Clinical Supervisor will review signed annual evaluations monthly and report findings to Program Director.
Completion Date: 1/6/17. |
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:
|
Observations
The facility failed to document that patients participated in the development of treatment plans in 3 of 8 records reviewed.
Patient #10 was admitted for treatment on 3/08/2016. The patient's treatment plan was signed by the counselor on 4/18/2016 but was not signed by the patient until 7/29/2016.
Patient #11 was admitted for treatment on 4/25/2016. The patient's treatment plan was signed by the counselor on 6/16/2016 but not signed by the patient.
Patient #13 was admitted for treatment on 7/26/2016. The patient's treatment plan was signed by the counselor on 8/22/2016 but not signed by the patient.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
Program Director provided a training to clinical staff on 1/5/17 addressing individual treatment plans, the patient participation in the development in their individual treatment plans, and the required written documentation. The Clinical Supervisor will review for approval before acceptance and signing off on treatment plans. The Program Director will review for compliance quarterly.
Completion Date: 1/5/17 |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
The facility failed to ensure that treatment plans were updated at least every 60 days in 4 of 9 patient records reviewed during the onsite inspection.
Patient #1 was admitted for treatment on 11/30/2015. The patient had a treatment plan update completed on 05/10/2016, but the next update was not completed until 07/29/2016.
Patient #4 was admitted for treatment on 01/27/2016. The patient had a treatment plan update completed on 07/13/2016, but the next update was not completed until 09/26/2016.
Patient #11 was admitted for treatment on 04/25/2016. The patient had a treatment plan update completed on 08/12/2016, but the next update was not completed until 10/29/2016.
Patient #13 was admitted for treatment on 07/26/2016. The patient had a treatment plan update completed on 09/23/2016, but the next update was not completed until 11/30/2016.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
Program Director provided a training to clinical staff on 1/5/17 addressing individual treatment plans, the patient participation in the development in their individual treatment plans, and the treatment plans required time of at least every 60 days to be reviewed and updated. The Clinical Supervisor will review for approval before acceptance and signing off on treatment plans. The Program Director will review for compliance quarterly.
Completion Date: 1/5/17 |