INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 18 through 20, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House New Castle 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 February 22, 2011.
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Plan of Correction
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705.23 (1) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(1) Maintain space for both individual and group counseling sessions.
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Observations
Based on division staff observation and an interview with the facility director, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room, as required by regulation.
The findings include:
The licensing inspection took place from January 18-20, 2011. During that time, division staff occupied two separate counselor offices while reviewing records. Both counselor offices were located off of the main hallway of the facility. Counseling sessions that were taking place in other offices were heard clearly through the walls.
An interview with the facility director took place on January 20, 2011. It was reported that plans are currently being made to rectify the problem.
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Plan of Correction
Physical Plant alterations to enhance sound proofing across counseling offices is currently in process. Interior wall windows are being removed and additional sound insulation is being applied in adjoining walls of counseling offices. The improvements are scheduled for completion on March 15, 2011. Facility Director is responsible for oversight. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of the project financial documents, the project failed to document an annual audit of financial activities associated with the project ' s drug/alcohol abuse services for the year ending December 31, 2009.
The findings include:
The project ' s financial documents were reviewed on January 18, 2011. A financial review was completed on March 25, 2010 by a contracted agency for the year ending December 31, 2009. Included in the documentation of that review was a letter including the following: " it is substantially less in scope than an audit in accordance to auditing standards generally accepted in the United States of America, the objective of which is the expression of an opinion regarding the consolidated financial statements taken as a whole. Accordingly, we do not express such an opinion. " This documentation was a financial review, not an audit and failed to meet the requirement of an annual audit of financial activities associated with the project ' s drug/alcohol abuse services.
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Plan of Correction
Discovery House will conduct an audit for fiscal year 2010. We will submit a 2009 compellation review and an engagement letter for 2010. Program Director will be charged to ensure task is completed. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to document the results of reference investigations in the personnel record, as required by regulation, in four of five personnel records.
The findings include:
Eight personnel records were reviewed on January 19, 2011. Five of the personnel records reviewed were that of new employees and documentation of reference investigations were required in all five of the new employee records. Reference investigations were not documented in personnel records # 5, 6, 7 and 8.
An interview with the facility director took place on January 19, 2011. At that time, it was confirmed that there was no documentation of reference checks for the previously mentioned employees. It was reported that the reference checks are being attempted/completed, however, not always documented.
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Plan of Correction
The Facility Director will be responsible to complete and document reference investigations for all new employees as required by regulation. Failed and successful reference investigations will be documented in the personnel record. Timeframe to complete investigations will be prior to hire. Corporate Director of Human Resources will be responsible for oversight. |
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 client records and an interview with the facility director, the facility failed to document complete personal histories, as required by regulation, in 9 of 10 client records.
The findings include:
Eighteen client records were reviewed on January 19 and 20, 2011. Eight of the client records were reviewed for closing documentation only. The remaining ten client records required documentation of a complete personal history. Client records # 1, 3, 4, 5, 10, 11, 12, 13 and 14 did not include complete personal histories.
Client #1 was admitted to treatment on August 18, 2010. The intake and admission paperwork, including the personal histories, were completed on August 18, 2010. The educational history and the employment/vocation history sections addressed only the current status and did not provide the client ' s history for those two areas.
Client #3 was admitted to treatment on August 13, 2010. The intake and admission paperwork, including the personal histories, were completed on August 13, 2010. The educational history and the employment/vocation history sections addressed only the current status and did not provide the client ' s history for those two areas.
Client #4 was admitted to treatment on November 24, 2010. The intake and admission paperwork, including the personal histories, were completed on November 24, 2010. The educational history and the employment/vocation history sections addressed only the current status and did not provide the client ' s history for those two areas.
Client #5 was admitted to treatment on October 27, 2010. The intake and admission paperwork, including the personal histories, were completed on October 26, 2010. The educational history and the employment/vocation history sections addressed only the current status and did not provide the client ' s history for those two areas.
Client #10 was admitted to treatment on August 6, 2010. The intake and admission paperwork, including the personal histories, were completed on August 6, 2010. The educational history and the employment/vocation history sections addressed only the current status and did not provide the client ' s history for those two areas.
Client #11 was admitted to treatment on November 17, 2010. The intake and admission paperwork, including the personal histories, were completed on November 16, 2010. The employment/vocation history section addressed only the current status and did not provide the client ' s history for this area.
Client #12 was admitted to treatment on December 14, 2010. The intake and admission paperwork, including the personal histories, were completed on December 7, 2010. The educational history and the employment/vocation history sections addressed only the current status and did not provide the client ' s history for those two areas.
Client #13 was admitted to treatment on October 8, 2010. The intake and admission paperwork, including the personal histories, were completed on October 7, 2010. The educational history and the employment/vocation history sections addressed only the current status and did not provide the client ' s history for those two areas.
Client #14 was admitted to treatment on August 30, 2010. The intake and admission paperwork, including the personal histories, were completed on August 26, 2010. The employment/vocation history section addressed only the current status and did not provide the client ' s history for this area.
An interview was conducted with the facility director on January 20, 2011 at which time it was confirmed that there was no additional personal history documentation available for review.
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Plan of Correction
An in-service training will be provided by the Clinical Supervisor for all clinical staff involved in the intake and admissions process. The training will address the documentation of personal histories and techniques on how to obtain the information. The Clinical Supervisor will be responsible to review psychosocial evaluations during clinical quality reviews to ensure compliance. Program Director will be responsible for oversight. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document follow up contact as required by facility policy and regulation in five of seven client records.
The findings include:
Facility policy requires follow up contact to be completed at 14 and 30 days after discharge. Eight discharged client records were reviewed on January 20, 2011. Seven of the client records reviewed required the documentation of a follow up as one client refused. Client records # 7, 8, 9, 15 and 18 did not contain documentation of follow up contact as required by facility policy and regulation.
Client #7 was admitted to treatment on February 26, 2010 and discharged on September 23, 2010. Follow up contact was required to be completed by October 7, 2010 and October 23, 2010. There was no documentation of follow up contact in client record #7. Other documentation stated that there was no release of information signed, so follow up could not be completed.
Client #8 was admitted to treatment on October 9, 2009 and discharged on November 4, 2010. Follow up contact was required to be completed by November 18, 2010 and December 4, 2010. There was no documentation of follow up contact in client record #8. Other documentation stated that there was no release of information signed, so follow up could not be completed.
Client #9 was admitted to treatment on October 22, 2009 and discharged on August 4, 2010. Follow up contact was required to be completed by August 18, 2010 and September 4, 2010. The first follow up contact was documented on August 19, 2010. There was no documentation of a 30 day follow up contact. Other documentation stated that there was no release of information signed, so the second follow up could not be completed.
Client #15 was admitted to treatment on September 3, 2009 and discharged on August 24, 2010. Follow up contact was required to be completed by September 7, 2010 and September 24, 2010. The follow up contact was completed on September 22, 2010 and October 7, 2010.
Client #18 was admitted to treatment on May 12, 2010 and discharged on November 3, 2010. Follow up contact was required to be completed by November 17, 2010 and December 3, 2010. The first follow up contact was completed on November 15, 2010. There was no documentation of a 30 day follow up contact. Other documentation stated that the second follow up contact could not be made as there was no release of information signed.
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Plan of Correction
The Clinical Supervisor will hold an inservice training concerning the regulation and facility policy requiring follow up contacts to be completed at 14 and 30 day intervals after discharge. The training will address the requirements and documentation. The Clinical Supervisor will address the documentation requirement in weekly supervision to ensure compliance. The training will be completed within the next 14 days. The Facility Director will do sporadic chart audits for oversight. |