INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16 - 18, 2008 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 October 20, 2008.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based upon a review of ten personnel records on September 16, 2008, and an interview with staff person #2 on September 17, 2008, it was determined that the facility failed to ensure that clinical supervisors and lead counselors who have not functioned for two years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision.
Findings:
Employee #3, the facility ' s only clinical supervisor, was promoted to that position on March 15, 2007 with one year of clinical supervisory experience and had not received the required core curriculum in clinical supervision as of September 18, the final date of the licensing inspection.
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Plan of Correction
The approved 5-day supervisor's training through BDAP in 2008 was cancelled. A re-schedule date of January 2009 has been released. The Clinical Supervisor will sign up for the training. The Program Director will monitor for compliance. Estimated time of completion: 2/01/09 |
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based upon a review of ten personnel records on September 16, 2008, and an interview with staff person #2 on September 17, 2008 it was determined that the facility failed to ensure that employee #6, one of one counselor assistants, was supervised by a full time clinical supervisor who met the qualifications in 704.6 or 704.7 (relating to the qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
Findings:
Employee #3, the facility ' s only clinical supervisor, was promoted to that position on March 15, 2007 with one year of clinical supervisory experience and had not received the required core curriculum in clinical supervision as of September 18, the final date of the licensing inspection.
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Plan of Correction
The approved 5-day supervisor's training through BDAP in 2008 was cancelled. A re-schedule date of January 2009 has been released. The Clinical Supervisor will sign up for the training. The Program Director will monitor for compliance. Estimated time of completion: 2/01/09 |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based upon a physical plant inspection on September 18, 2008, the facility failed to maintain the building grounds of the facility in a clean safe manner free of hazards.
Findings:
There was debris and broken glass along the side of the building adjacent to Negley Run Boulevard.
There were pieces of pipe with jagged edges sticking up from the ground where an old railing had been cut and removed near the exit adjacent to Negley Run Boulevard. These pipes protruded approximately two inches.
There was a section of a concrete barrier with rebar that was broken and leaning to the point that it created a possible tripping hazard in the vicinity of the exit discharge adjacent to Negley Run Boulevard.
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Plan of Correction
Clinic staff will immediately clean up debris around area and mark tripping hazards until area can be properly cleaned of all hazards by the public works authority. Program Director will monitor for compliance. Estimated time of completion: 1/10/09 |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based upon a physical plant inspection on September 18, 2008, the facility failed to ensure privacy so that counseling sessions could not be seen or heard outside the counseling room.
Findings:
One of the counselor ' s offices had a door (#108) with a large glass vision panel that lacked proper window treatment to prevent others from seeing into the office.
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Plan of Correction
The counselor's office door in question will have a blind installed to protect the confidentiality of all patients seen in that office. Program Director will monitor for compliance. Expected date of completion: 11/15/08. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based upon a physical plant inspection on September 18, 2008, the facility failed to ensure that exits were unobstructed.
Findings:
There were doors in the path of egress that were able to be locked against egress in the following locations:
The corridor door for the file room which would require a key to open.
The control door leading to the administrative area which had a simplex combination lock.
The exterior door from the garage/closed file storage area which had two sliding dead bolts.
The second means of egress from the second floor was obstructed on the day of the physical plant inspection for the following reasons:
To access this particular exit you must go through a counselor ' s office which is kept locked when the clinician is not in the office.
The slide down stair was not easily operable at the time of the inspection and need some maintenance performed on them to make them more easily operable.
The positioning of the tables in the group room at the time of the inspection interfered with the ability to lower them all the way to rest on the floor.
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Plan of Correction
The local fire code inspector toured our facility on 10/31/08 and approved all egress' in the building. The inspector suggested some changes to our current plan and current exit signs. We will re-do the evacuation plans to show proper egress' in the event of an emergency and mark and/or remove the exits accordingly. Estimated date of completion: 11/14/08. The second floor egress stairway needs repaired and parts were ordered. Estimated date of completion for repair: 11/30/08. The placement of the tables and chairs in the group room will be situated in a way that will not obstruct the use of the stairway. All doors will remain unlocked against required egress' during operating hours. Program Director will monitor for compliance. This will be immediate and ongoing. |
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 upon a review of the facility ' s 2007 annual report on September 16, 2008, the facility failed to include a financial statement of income and expenses.
Findings:
No financial statement of income and expenses were provided in the annual report.
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Plan of Correction
All future annual reports will contain the relevant financial information. Program Director and Home Office will monitor for compliance. Estimated time of completion: 6/01/2009 |
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 upon a review on September 17, 2008, of the facility ' s balance sheets and accompanying letter of March 6, 2008 provided by Restivo Monacelli LLP Certified Public Accountants and Business Advisors, the project failed to obtain an independent audit of all financial activities associated with the project ' s drug/alcohol abuse services.
Findings:
The letter dated March 4, 2006 from the Accounting firm indicated that the accounting methods used were other than generally accepted principals and that they did not audit or review the accompanying financial statements and supplementary schedules, and accordingly do not offer an opinion or form of assurance on them.
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Plan of Correction
Discovery House will obtain an independent audit of all financial activities associated with the project's drug abuse services. Program Director and Home Office will monitor for compliance. Estimated date of completion: 6/01/2009 |
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:
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Observations
Based upon a review of eight client records on September 17 & 18, 2008, the facility failed to obtain informed and voluntary consents to release information in six of six applicable records reviewed.
Findings:
Client records #1, 2, 3, 4, 5 & 6 all contained drug screen test results from Quest Laboratories; however, there was no Quality Service Organization Agreement in place with the laboratory, nor were there any consents to release information to the laboratory.
Client records #1, 2, 3, 4, 5 & 6 all contained consents to release information forms which did not allow for the verbal revocation of the consent.
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Plan of Correction
Discovery House obtained a QSOA with Quest Laboratories in September, 2008. Our home office has re-formatted the electronic release forms to allow verbal revocations of the consent forms. Program Director will monitor for compliance. Estimated date of completion: 11/7/2008 |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based upon a review of eight client records on September 17 & 18, 2008, the facility failed to document that the client was offered a copy of the consent to release information in six of six applicable records reviewed.
Findings:
Client records #1, 2, 3, 4, 5 & 6 all contained consents to release information forms which did not indicate that the client was offered a copy of the consent, nor was there any other documentation available in the client records to indicate that the client had been offered a copy.
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Plan of Correction
Discovery House's home office is currently re-formatting the electronic consent forms to include confirmation that the patient was offered a copy. Program Director will monitor for compliance. Estimated date of completion: 1/10/2009 However, in the interim, counselors will print out hard-copy forms and have the patient sign the form whether they received a copy or refused a copy. Clinical Supervisor will monitor for compliance. This will be immediate and ongoing until the software is changed. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based upon a review of eight client records on September 17 & 18, 2008, the facility failed to complete the psychosocial evaluations at intake as per the facility ' s policy and procedures in six of six applicable records reviewed.
Findings:
Client record #1 admission date 4/16/08 psychosocial evaluation completed 4/22/08.
Client record #2 admission date 4/10/08 psychosocial evaluation completed 4/11/08.
Client record #3 admission date 3/27/08 psychosocial evaluation completed 3/28/08.
Client record #4 admission date 4/28/08 psychosocial evaluation completed 5/01/08.
Client record #5 admission date 3/12/08 psychosocial evaluation completed 3/13/08.
Client record #6 admission date 4/01/08 psychosocial evaluation completed 4/02/08.
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Plan of Correction
Discovery House's home office is currently addressing this issue with our policy department. This department will re-work this policy to indicate that the psychosocial evaluations will be done within the intakes first week of treatment, rather than stating it be complete upon intake. Program Director will monitor for compliance. Estimated date of completion: 11/19/2008 |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based upon a review of eight client records on September 17 & 18, 2008, the facility failed to complete the preliminary treatment plans at intake as per the facility ' s policy and procedures in six of six applicable records reviewed.
Findings:
Client record #1 admission date 4/16/08 preliminary treatment plan completed 4/18/08.
Client record #2 admission date 4/10/08 preliminary treatment plan completed 4/14/08.
Client record #3 admission date 3/27/08 preliminary treatment plan completed 3/28/08.
Client record #4 admission date 4/28/08 preliminary treatment plan completed 4/29/08.
Client record #5 admission date 3/12/08 preliminary treatment plan completed 3/13/08.
Client record #6 admission date 4/01/08 preliminary treatment plan completed 4/08/08.
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Plan of Correction
Discovery House's home office is currently addressing this issue with our policy department. This department will re-work this policy to indicate that the preliminary treatment plans will be done within the intakes first week of treatment, rather than stating it be complete upon intake. Program Director will monitor for compliance. Estimated date of completion: 6/10/2009 |
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 upon a review of eight client records on September 17 & 18, 2008, the facility failed to complete the comprehensive treatment plan within 30 days of the preliminary treatment plans to be completed at intake as per the facility ' s policy and procedures in five of six applicable records reviewed.
Findings:
Client record #2 admission date 4/10/08 comprehensive treatment plan due 5/10/08 completed 5/13/08.
Client record #3 admission date 3/27/08 comprehensive treatment plan due 4/27/08 completed 4/29/08.
Client record #4 admission date 4/28/08 comprehensive treatment plan due 5/28/08 completed 5/29/08.
Client record #5 admission date 3/12/08 comprehensive treatment plan due 4/12/08 completed 4/15/08.
Client record #6 admission date 4/01/08 comprehensive treatment plan due 5/01/08 completed 5/06/08
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Plan of Correction
Clinical supervisor will hold an in-service training dealing with comprehensive treatment plans, which will include when the plans are due. Clinical supervisor will monitor for compliance. Estimated completion date for the training: 11/30/2008. Treatment plans will be completed in the time they are due on an ongoing basis after the training. Clinical supervisor will monitor for compliance. |