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 2 & 3, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Discovery House 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of nine personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #9 was hired on June 20, 2022 as a counselor assistant and was still employed at the time of the inspection. Employee #9 has a bachelor ' s degree with less than one year experience and may counsel patients only under close supervision of a lead counselor or clinical supervisor for the first 6 months of employment. Employee #9 did not receive close supervision once a week from June 2022 - October 2022. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week." During documented supervision only formal case reviews were occurring once a month.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
REVISED: The requirements outlined in section 704.9 and 704.10 relating to counselor assistants will be implemented and followed. The clinical supervisor will meet with the counselor assistant weekly to provide formal documented case reviews and will provide an additional hour of direct observation of a group or individual session. The clinical supervisor is responsible for the compliance of this standard. Implementation of this standard will begin immediately and reviewed on an on-going basis.
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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 July 3-July 9, 2022, the patient census was 330. The facility was required to provide at least 33 physician hours. There were 4.5 physician hours documented.
During the week of August 7-13, 2022, the patient census was 327. The facility was required to provide at least 32.7 physician hours. There were 14 physician hours documented.
During the week of August 28-September 3, 2022, the patient census was 324. The facility was required to provide at least 32.4 physician hours. There were 10 physician hours documented.
During the week of September 4-9, 2022, the patient census was 327. The facility was required to provide at least 32.7 physician hours. There were 10 physician hours documented.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The physician will provide the required on-site hours. The physician is responsible for providing 1 hour for every 10 patients. This will be reviewed at the staff meeting held on 11/29/2022. The clinic director is responsible for monitoring and approving the hours spent on-site by the physician and physician assistant. This will be implemented immediately and monitored on an on-going basis. |
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.
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Observations
Based on a review of client records, the facility failed to provide each patient with an average of 2.5 hours of psychotherapy per month during the patient ' s first two years of treatment in six out of six applicable records reviewed.
Patient #1 was admitted on January 10, 2022 and was still active at the time of the inspection. There was no documentation of the patient having any hours of psychotherapy for the months of July, August, September, or October 2022. There was no documentation of the patient no shows or cancellations during those time periods.
Patient #3 was admitted on June 24, 2022 and discharged on August 26, 2022. The patient only had half an hour of individual therapy in June of 2022 and one hour of individual therapy in July 2022.
Patient #4 was admitted on September 14, 2022 and still active at the time of the inspection. The patient received only 2 hours of individual therapy in September 2022 and one hour of individual therapy in October 2022. There was no documentation of the patient no shows or cancellations during those time periods.
Patient #6 was admitted on August 5, 2021 and was still active at the time of the inspection. The patient received only one and half hours of individual therapy in October 2022. There was no documentation of the patient no shows or cancellations during those time periods.
Patient #8 was admitted on December 2, 2021 and discharged on June 27, 2022. The patient received only two hours of individual therapy in February 2022. There was no documentation of the patient no shows or cancellations during those time periods.
Patient #9 was admitted on January 19, 2022 and was still active at the time of the inspection. There was no documentation of the patient having any hours of psychotherapy for the months of July, August, September, and October 2022. There was no documentation of the patient no shows or cancellations during those time periods.
This is a repeat citation from the December 3, 2021 licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All patients for the first two (2) years will do the required 2.5 hours of counseling per month. Counselors will make every effort to have the counseling completed each month. If the patient does not show a no- show note will be placed in the EMR to show attempts to get the required hours. This will be addressed in the December 2022 counselor staff meeting. This will be monitored by the clinical supervisor and the clinic director |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of client records, the facility failed to provide patients with at least one hour of group or individual psychotherapy every two months for each patient in treatment over four years in two out of three applicable records reviewed.
Patient #5 was admitted on September 27, 2013 and discharged on March 29, 2022. There was no documentation of psychotherapy occurring in December 2021, January 2022, or March of 2022. There was no documentation of the patient no shows or cancellations during those time periods.
Patient #7 was admitted on May 25, 2018 and was still active at the time of the inspection. There were no hours of psychotherapy in the months of July and August of 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
After four (4) years of treatment patients will be required to complete one (1) hour of group or individual counseling every two (2) months. Counselors will make every effort to have the counseling completed timely. If the patient does not show a no- show note will be placed in the EMR to show attempts to get the required hours. This will be addressed in the December 2022 counselor staff meeting. This will be monitored by the clinical supervisor and the clinic director.
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715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient in one out of one applicable record reviewed.
Patient #4 was admitted on September 14, 2022 and was still active at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The nursing staff will be responsible for completing a Patient Transfer Agreement form for all patients that transfer into the clinic and notify the transferring narcotic treatment program of the admission and the date the initial dose was given to the patient. A training with the nursing staff was held on December 8, 2022, to explain the use of the Patient Transfer Agreement form. This will be monitored monthly by the nursing supervisor through the use of chart audits. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on the review of patient records, the facility failed to document the results of an initial intake physical examination within the regulatory timeframe in four out of five applicable records reviewed.
Patient #1 was admitted on January 10, 2022 and was still active at the time of the inspection. An initial physical examination was completed on January 10, 2022 by the Physician Assistant; however, the medical doctor did not review and countersign within three days, it wasn't signed until January 31, 2022.
Patient #3 was admitted on June 24, 2022 and was discharged on August 26, 2022. An initial physical examination was completed on June 24, 2022 by the Physician Assistant; however, the medical doctor did not review and countersign within three days, it wasn't signed until June 30, 2022.
Patient #8 was admitted on December 2, 2021 and was discharged on June 27, 2022. The initial physical examination was completed on December 2, 2021 by the Physician Assistant; however, there was no documentation that the medical doctor reviewed and signed.
Patient #9 was admitted on January 19, 2022 and was still active at the time of the inspection. An initial physical examination was completed on January 19, 2022 by the Physician Assistant; however, the medical doctor did not review and countersign within three days, it wasn't signed until January 31, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The narcotic treatment physician or the physician assistant will complete an annual physical examination this exam will be documented in the patient medical record. The annual physical exam completed by the physician assistant will be reviewed and signed by the treatment physician within three (3) business days. This was reviewed at the staff meeting on 11/29/2022. This will be monitored by the clinic director on an on-going basis |
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 #2 was admitted on June 16, 2015 and was still active at the time of the inspection. The annual physical examination was completed on June 15, 2022, by the Physician Assistant; however, it was not reviewed and signed by the medical doctor within three days.
Patient #6 was admitted on August 5, 2021 and was still active at the time of the inspection. An annual physical examination was completed on August 4, 2022, by the Physician Assistant; however, it was not reviewed and signed by the medical doctor within three days.
This is a repeat citation from the December 3, 2021 licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The physician or physician assistant is responsible for completing the patient's annual physical. The physician or physician assistant will complete the annual physical exam including the full documentation of a re-evaluation on the patient on a timely basis. The physician will sign ? off on the medical record within the required timeframe. This will be addressed with the physician and physician assistant in the medical staff meeting on 11/29/2022. The clinic director is responsible for compliance with the standard. Implementation will begin immediately and reviewed on an on-going basis. |
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 a review of patient records, the facility failed to complete an annual evaluation of each patient ' s status by the patient ' s counselor in one out of four applicable records.
Patient #6 was admitted on August 5, 2021 and was still active at the time of the inspection. An annual evaluation was due no later than August 5, 2022; however, it was not documented until October 31, 2022.
This is a repeat citation from the December 3, 2021 and December 11, 2020 licensing inspections.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
REVISED: DHBC counselors will perform an annual evaluation of each patient the review will be documented in the patient's medical record. The DHBC counselor will review the clients due for their annual evaluation at the beginning of each month. The counselor will complete the annual evaluation prior to the client's anniversary date. DHBC counselors will report weekly to the clinical supervisor the status of the annual evaluations due. The medical director will review date and sign the evaluation. The issue will be addressed at the staff meeting in December 6, 2022. This will be monitored by the clinical supervisor during the monthly record review.
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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 the review of client records, the facility failed to develop an individual treatment and rehabilitation plan with the client within their policy ' s set time frame of 8-30 days.
Client #3 was admitted on June 24, 2022 and was discharged on August 26, 2022. An individual treatment plan was due no later than July 24, 2022; however, it wasn ' t documented until July 28, 2022. The treatment and rehabilitation plan did not include the client ' s signature.
Client #4 was admitted on September 14, 2022 and was still active at the time of the inspection. An individual treatment plan was due no later than October 14, 2022; however, it was documented until October 26, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
DHBC counselors will complete an individual treatment and rehabilitation plan within the first eight (8) to thirty (30) days of treatment, the treatment plan will be documented in the patient's medical record. This issue will be addressed at the staff meeting in December 2022. This will be monitored by the clinical supervisor during the monthly medical record review.
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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.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven applicable records reviewed.
Client #1 was admitted on January 10, 2022 and was still active at the time of the inspection. A treatment plan update was completed on March 8, 2022 and the next update was due no later than May 8, 2022; however, it was not documented until May 13, 2022. The next update was due no later than July 13, 2022; however, it was not documented until July 28, 2022. The next update was due no later than September 13, 2022; however, it was not documented until September 22, 2022.
Client #6 was admitted on August 5, 2021 and was still active at the time of the inspection. A treatment plan update was completed on January 27, 2022 and the next update was due no later than March 27, 2022; however, it was not documented until April 7, 2022. The next update was due no later than June 7, 2022; however, it was not documented until June 22, 2022. The next update was due no later than August 22, 2022; however, it was not documented until August 31, 2022.
Client #8 was admitted on December 2, 2021 and discharged on June 27, 2022. A treatment plan update was completed on April 7, 2022 and the next update was due no later than June 7, 2022; however, it was not documented until June 24, 2022.
Client #9 was admitted on January 19, 2022 and was still active at the time of the inspection. A treatment plan update was completed on March 14, 2022 and the next update was due no later than May 14, 2022; however, it was not documented until May 20, 2022. The next update was due no later than July 20, 2022; however, it was not documented until July 28, 2022. The next update was due no later than September 28, 2022; however, it was not documented until September 30, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
DHBC counselors will review and update patient's treatment plans on a regular basis but at least every sixty (60) days. The review will be documented in the patient's medical record. This issue will be addressed at the staff meeting in December 2022. This will be monitored by the clinical supervisor during the monthly records review.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of patient records, the facility failed to ensure that the patients received counseling services according to their individual comprehensive treatment plan in eight out of nine records reviewed.
Patient #1 was admitted on January 10, 2022 and was still active at the time of the inspection. The treatment plan, dated February 14, 2022, indicated two and half hours of individual or group per month with at least one hour individual a month. The record of service and progress notes indicated that the patient had received no individual or group sessions for the months of July, August, September or October 2022.
Patient #3 was admitted on June 24, 2022 and discharged on August 26, 2022. The treatment plan, dated June 27, 2022, indicated two and half hours of individual or group per month with at least one hour individual a month. The record of service and progress notes indicated that the patient had received a total of one and half hours of individual sessions during the month of July 2022.
Patient #4 was admitted on September 14, 2022 and was still active at the time of the inspection. The treatment plan, dated September 14, 2022, indicated two and half hours of individual or group per month with at least one hour individual a month. The record of service and progress notes indicated that the patient had received a total of one hour of individual session during the month of October 2022.
Patient #5 was admitted on September 27, 2013 and was discharged on March 29, 2022. The treatment plan, dated November 30, 2021, indicated one hour of group or individual session every other month. The record of service and progress notes indicated that the patient had received a total of one hour of individual session in the months of December 2021, January, February and March 2022.
Patient #6 was admitted on August 5, 2021 and was still active at the time of the inspection. The treatment plan, dated September 23, 2022, indicated two and half hours of individual or group per month with at least one hour individual a month. The record of service and progress notes indicated that the patient had received a total of one and half hours of individual session during the month of October 2022.
Patient #7 was admitted on May 25, 2018 and was still active at the time of the inspection. A treatment plan, dated May 26, 2022, indicated, one hour of group or individual session every other month. The record of service and progress notes indicated that the patient had received a total of half an hour of individual session in the months of July, August, September, and October 2022.
Patient #8 was admitted on December 2, 2021 and discharged on June 27, 2022. The treatment plan, dated December 29, 2022, indicated two and half hours of individual or group per month with at least one hour individual a month. The record of service and progress notes indicated that the patient had received a total of two hours of individual sessions during the month of February, March, April, and May 2022.
Patient #9 was admitted on January 19, 2022 and was still active at the time of the inspection. The treatment plan, dated May 20, 2022, indicated two and half hours of individual or group per month with at least one hour individual a month. The record of service and progress notes indicated that the patient did not receive any psychotherapy hours during the months of July, August, September, and October 2022.
This is a repeat citation from the December 3, 2021 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
REVISED: DHBC counselors will continually review individual patient's treatment and rehabilitation plan and provide treatment based on the individuals plan on file in the patient record. The DHBC counselor will place holds on clients who need individual/group counseling based on their individual treatment plans to schedule the appointment. The counselor will call the patient the day before the scheduled appointment to remind the patient. The counselor will place a hold on the patient the day of the appointment. If the client is a no show, this will be noted in the EMR and a follow up call will be made to the client. The issue will be addressed at the staff meeting in December 6, 2022. This will be reviewed and monitored by the clinical supervisor during the monthly record review.
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