INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on April 26, 2017 by staff from the Division of Accountability and Program Improvement. Based on the findings of the on-site complaint investigation, Discovery House CU-Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
A physical plant inspection was conducted on April 26, 2017. Based on this inspection, the facility failed to be free from rodent infestation.
During the physical plant walk through mouse excrement was observed under the kitchen sink in the staff kitchen and in a closet off the hallway.
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Plan of Correction
On May 5, 2017, Orkin Pest Control was notified to do an internal and external inspection of the facility. After the inspection, an agreement was signed. On May 10,2017 Orkin did their first on site visit to free our facility from rodents.
Luzier Cleaning Services was notified to re-clean and sanitize the facility effective immediately. The Program Director will be incontact with each vendor to get updates on the progress and will inspect the facility on a weekly basis. |
715.6(a)(2) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
(2) When a narcotic treatment program is unable to hire a medical director who meets the qualifications in paragraph (1), the narcotic treatment program may hire an interim medical director. The narcotic treatment program shall develop and submit to the Department for approval a training plan for the interim medical director, addressing the measures to be taken for the interim medical director to achieve minimal competencies and proficiencies until the interim medical director meets qualifications identified in paragraph (1)(i), (ii) or (iii). The interim medical director shall meet the qualifications within 36 months of being hired.
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Observations
A review of employee personnel records was conducted on April 26, 2017. Based on this review, the facility failed submit to the Department, for approval, a training plan for the interim medical director.
A review of the interim medical director's personnel file revealed that he did not have three years documented experience in the provision of services to persons who are addicted to alcohol or other drugs.
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Plan of Correction
Prior to hiring a medical director the Program Director will review the state regulations pertaining to the qualifications of an interim medical director to ensure he/she meets the qualifications. If the interim medical director does not meet the requirements, the narcotic treatment program shall develop and submit to the D.O.H for approval a training plan addressing measures that will be taken for the interim medical director to achieve the qualifications within the specified time frame. The Program Director will monitor to ensure the interim director meets the qualifications within the specified time frame. A revised training plan for Dr Hall was submitted to the D.O.H on 05/17/2017 for approval. |