INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on April 16-18, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Discovery House, Inc. 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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709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of administrative documentation, the facility failed to include a financial statement of income and expenses in the annual report made public for the year reviewed, 2010.
The findings include:
The annual report was reviewed April 17, 2012. A financial statement of income and expenses was not included in the annual report presented for review.
This was discussed with the facility director and was not disputed.
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Plan of Correction
Discovery House will include a financial statement of income and expenses in the June 2012 Annual Report. The Annual report including the financial statement of income and expenses will be to the Department of Health division of program licensure upon completion. This financial audit documentation will meet the acceptable auditing standards requested and will be addressed/completed according to the state requirements. The responsible parties for this correction will be the Program Sponsor and the Program Director.
Furthermore, the Program Sponsor and Program Director will take the necessary steps to ensure that the financial audit of fiscal activities is completed on an annual basis and will meet with designees from Discovery House, Inc to identify the mandatory requirements attached to this audit to prevent the reoccurrence of this citation in the future. This annual audit will meet the state standards and Discovery House, Inc. will assume responsibility for ensuring that this audit will be done annually hereafter unless otherwise deemed by the state auditing authority.
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709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on the review of client records, the facility failed to ensure verbal medication orders were signed within 24 hours by the prescribing physician in two of three client records reviewed.
The findings include:
Client record # 1 contained documentation of verbal orders that were not signed by the prescribing physician within 24 hours as required. There was a verbal order issued on February 9, 2012 that was signed on February 12, 2012; a verbal order was issued on February 16, 2012 and not signed until February 20, 2012; a verbal order was issued on February 24, 2012 and signed on February 26, 2012; and a verbal order issued on March 3, 2012 was signed on March 5, 2012.
Client record # 7 contained documentation of verbal orders that were not signed by the prescribing physician within 24 hours as required. There was a verbal order issued on October 27, 2011 and signed November 2, 2011; a verbal order issued on October 28, 2011 and signed on November 2, 2011; a verbal order issued on October 29, 2011 and signed on November 2, 2011; a verbal order issued on November 10 that was signed on November 14, 2011 and an order written on January 14, 2012 that was for January 12, 2012.
This is a repeat deficiency from the July 27, 2011 inspection.
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Plan of Correction
The Program Director will provide a refresher inservice with the physicians and Nurse Manager to review the protocol for signing verbal orders.
The Program Director will provide the Nurse Manager with a refresher inservice on how to monitor veral orders.
The program Physician's will check daily and sign all verbal orders within 24-hours of issuing them.
The Nurse Manager will audit orders daily and communicate with the physicians when verbal order signatures are due.
The Program Director is responsible for implementing the process and ensuring ongoing compliance with the procedure.
The target date for the development and implementation of the process is 5/08/12.
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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 the client records, the facility failed to provide a personal history that included detail in the areas of family history, legal history, employment/vocational history, education history, recreational and sexual history in five of five client records.
The findings include:
Nineteen client records were reviewed April 16-18, 2012. Five client records were reviewed specifically for personal history documentation. Five client records failed to include a detailed personal history.
Client # 1 was admitted February 6, 2012. The areas of family, legal, recreational and sexual histories consisted of one or two word responses and did not detail the client's history in each of these areas.
Client # 2 was re-admitted January 17, 2012 as a drug-free client after being discharged from medication assisted treatment. There was no personal history information at the time of the inspection.
Client # 4 was admitted March 12, 2012. The areas of family, legal, recreational and sexual histories consisted of one or two word responses and did not detail the client's history in each of these areas.
Client # 5 was admitted August 24, 2011. The areas of family, legal, recreational and sexual histories consisted of one or two word responses and did not detail the client's history in each of these areas.
Client # 7 was admitted October 26, 2011. The areas of family, legal, recreational and sexual histories consisted of one or two word responses and did not detail the client's history in each of these areas.
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Plan of Correction
The Clinical Supervisor will provide a refresher In-Service with the Counselor's to reiterate the importance of continuing to provide details in the Assessment. The In-Service will reiterate the need to include details in the areas of family history, employment/vocational history, militry history, recreational history, prior treatment, client's perception of drug use, family drug abuse history and sexual history.
The target date for the development and implementation of the process is 5/8/2012. The Clinical Supervisor will review a sampling of Assessments to ensure it has adequate detail.
The Director is responsible for ensuring ongoing compliance.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of patient records and discussion with administrative staff, the facility failed to develop an aftercare plan in one of one client records reviewed.
The findings include:
Nineteen client records were reviewed April 16-18, 2012. Eight of those nineteen were of discharged client records. One of the eight discharged records required an aftercare plan.
Client # 16 was admitted June 7, 2010 and discharged February 7, 2012. The facility annually reviews aftercare plans that are developed shortly after admission, but they are generalized and formatted in such a manner as to not be relevant to the client's actual needs after treatment. The facility had last reviewed the aftercare plan of client # 16 June 3, 2011. A relevant and updated aftercare plan was not developed with the client prior to discharge February 7, 2012. There was no documentation a copy of the June 3, 2011 aftercare plan was offered to the client prior to the February 7, 2012 discharge.
This was discussed with the facility director April 18, 2012 and was not disputed.
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Plan of Correction
The Clinical Supervisor will hold an in-service w/ the Counselor's to review the importance and requirement to develop an aftercare plan with each patient. The Clinical Supervisor will audit a random sampling of charts to ensure that aftercare plans are completed on schedule.
The Clinical Supervisor will implement the in-service and random audit sampling by May 8, 2012.
The Director is responsible for ensuring the process is implemented and followed.
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