INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 15 - 16, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, 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 and a plan of correction is due on December 14, 2007.
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of the personnel training records on 11-15-07 and a conversation with the Director, the facility failed to provide documentation of STD/TB training for employee records # 6 and 7.
|
Plan of Correction
Employee #1 was scheduled to attend STD/TB training 11/23/07 and has completed this training. Employee #2 is used as a PRN nurse and will provide documentation of this training asap. |
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. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on a review of the client records on 11-15-07 and 11-16-07, the facility failed to provide a valid consent for the disclosure of information in three of eight client records. The consent to release information forms found in those client records do not indicate what specific information is to be released. There are three options on the consent to release information form, " release to, obtain from and/or verbal release of information". The consent to release information forms in the client records indicate that information is to be "obtained from" someone, and that the release of information will be "verbal", but the forms fail to indicate "why" the information will be released and "what" information will be released. Refer to client records #3, 7 and 8.
|
Plan of Correction
The Clinical Supervisor will address this issue in direct supervision with each counselor and the Program Director will address the medical associates on release of information forms and how to properly fill the forms out. Each new associate will also be properly trained in release forms throughout the year in direct supervision. |
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
Based on a review of the client records on 11-15-07 and 11-16-07, the facility failed to provide a review of the progress on the treatment plan updates. Progress is lacking in three of five applicable client records. Refer to client records # 1, 2 and 3.
|
Plan of Correction
Because these records were mainly from our newest counselors, our Clinical Supervisor will be addressing this issue in direct supervision with each counselor, making sure every treatment plan documents any progress, or lack thereof, for every patient. Each treatment plan will document progress using a narrative format including 'SNAP' and will also include any changes with the patient. Clinical Supervisor will be responsible for monitoring progress. |