INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 4, 2007 through December 6, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House - HA 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 January 9, 2007.
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Plan of Correction
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill log and an interview with the facility director the facility failed to clearly document that alternate exit routes had been prepared for use during the fire drills.
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Plan of Correction
705.28(d)(5)
The Health and Safety team will provide a training to staff on the use of alternative exits. Drills conducted will include documentation stating which exits were used and which exits were blocked if applicable. The health and Safety Captain will be responsible. (Vivian Wright)
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709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of administrative and program policy and procedure from December 4, 2007 to December 6, 2007 the written procedures for the management of treatment/rehabilitation services included corporate policies, with unclear or no time frames that were not specific to this facility in Pennsylvania. Several timeframes were missing, such as those for preliminary treatment plans, case consults, treatment plan updates, and the intake information.
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Plan of Correction
Policy will be amended to include a written plan for the coordination of client treatment and rehabilitation services as well as procedures for the management of treatment /rehabilitation services for clients which will include time frames and who's responsible. Director will be responsible. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on the review of the administrative policy and procedure manual and material and on interviews with the facility director on December 6, 2007 the written policy and procedures for the confidentiality of electronic records is incomplete and inaccurate. The written policy and procedure stated that the electronic records will be secured in accordance with the HIPAA regulations and fails to address the more stringent federal regulations at 42 CFR Part 2, Subparts A through E which prohibit some releases that are permitted by the HIPAA regulations. The written policy and procedure for electronic records also failed to consider the more stringent requirements in state law at 71 P. S. Subsections 1690.102 through 1690.112 and the state regulations at 4 Pa. Code subsection 255.5 and 28 Pa. Code Subsection 709.28 (c).
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Plan of Correction
Policy will be amended to show that Confidentiality of electronic records meets all conditions of state law, state regulations, as well as federal regulations. Director will be responsible. |
709.28(a)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(2) Staff access to client records.
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Observations
Based on the review of the administrative policy and procedure manual and material and on interviews with the facility director on December 6, 2007 the written procedures failed to identify by job title those individuals with access to client identifying information. The written procedures fail to describe how access to confidential client information is gained.
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Plan of Correction
Policy will be amended to show who has access and how they obtain this access to confidential client information. Director will be responsible. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on the review of the administrative policy and procedure manual and material and on interviews with the facility director on December 6, 2007 there was no way to determine if the client identifying information stored electronically on the SMART system is being maintained in accordance with the federal and state confidentiality regulations since the system has been constructed to comply with HIPAA regulations which do not rise to the level of security described at 42 CFR Part 2, Subpart A, Subsection 2.16.
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Plan of Correction
Policy will be amended to show that Client identifying information stored on the SMART system is being maintained in accordance with the federal and state confidentiality regulations. Director will be responsible. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records on December 5 and 6, 2007 the facility released information in excess of the limitations imposed at 4 Pa. Code subsection 255.5 (b) to single county authorities and other third party payers in 9 of 13 client records reviewed. These documents were found in client records # 2, 3, 4, 5, 6, 7, 8, 9 and 10.
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Plan of Correction
A in-service training will be provided to all staff on confidentiality as it pertains to release of information for single county authorities and third party payers as well as documenting purpose of release. Clinical Supervisor and Director will be responsible. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records on December 5 and 6, 2007 the facility allowed for the purpose of a release to third party payers to be listed as "Release to 3rd Party Payor" which is not a purpose at all. This was documented in 7 of 12 client records reviewed, specifically client records # 3, 4, 5, 6, 7, 8 and 12.
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Plan of Correction
A in-service training will be provided to all staff on confidentiality as it pertains to release of information for single county authorities and third party payers as well as documenting purpose of release. Clinical Supervisor and Director will be responsible. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records on December 5 and 6, 2007 the facility failed to document notification of termination in 4 of 5 client records reviewed. Documentation of notice of termination was missing from client records # 9, 10, 11 and 14.
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Plan of Correction
The administrative withdrawal notice currently being used will be amended to include the reason for termination. A training will follow on including reason for termination and documenting this on the administrative withdrawal notice. Director will be responsible. |
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 from December 5, 2007 to December 6, 2007 the personal histories were incomplete in 9 of 13 client records reviewed, missing employment history and/or recreational history and/or legal history. Employment and recreational history was incomplete or missing from client records # 1, 4, 5, 11, 12 and 13. Legal history was incomplete or missing from client records # 3, 4, 5, 6, 9 and 13.
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Plan of Correction
A in-service training for all staff completing intake and admissions will be provided on documenting Histories and personal histories obtained through the intake procedures and importance of this information and different techniques on how to obtain this information. Clinical Supervisor to review psychosocial evaluations during clinical quality reviews to ensure compliance. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of client records from December 5, 2007 to December 6, 2007 the facility failed to ensure that evaluative material was included in the documents for psychosocial evaluation in 13 of 13 client records reviewed. The facility did not provide for evaluative statements relative to the client's problems and needs; assets and strengths; support systems; coping mechanisms and negative factors in client records #1 through #13.
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Plan of Correction
A in-service training for all staff completing intake and admissions will be provided on using evaluative material when completing a psychosocial evaluation. This training will focus on evaluative statements relative to the client's problems and needs, assets and strengths, support systems and coping mechanisms and negative factors. Clinical Supervisor to review psychosocial evaluations during clinical quality reviews to ensure compliance. |
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 a review of client records from December 5, 2007 to December 6, 2007 the facility failed to provide for individualized treatment plans in client records #1 through #13. The treatment plans were alike from client record to client record with little variation or indication of an attempt to write an individualized treatment plan.
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Plan of Correction
A in-service training will be provided on writing individualized treatment plans. Outside trainings will also be utilized for staff needing additional training. Clinical Supervisor to review Treatment plans before being posted as completed to ensure compliance. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records on December 5 and 6, 2007 the facility failed to specify on the treatment plans in client records #1 through 13 how often group and/or individual sessions would be provided within a specified time period.
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Plan of Correction
A in-service training will be provided on writing individualized treatment plans. This training will also review standards associated with type and frequency of treatment and how to clearly document this on the treatment plan. Outside trainings will also be utilized for staff needing additional training. Clinical Supervisor to review Treatment plans before being posted as completed to ensure compliance. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records on December 5 and 6, 2007 the facility failed to document support services on the treatment plans in client records #1 through 13.
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Plan of Correction
A in-service training will be provided on writing individualized treatment plans. This training will also review standards associated with documentation of proposed support services. Outside trainings will also be utilized for staff needing additional training. Clinical Supervisor to review Treatment plans before being posted as completed. Clinical Supervisor and Director will be responsible. |
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 on December 5 and 6, 2007 the facility failed to document the clients' progress or lack of progress in relation to the stated goals in client records #1 through 13.
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Plan of Correction
A in-service training will be provided on writing individualized treatment plans. This training will also review standards associated with documentation of the clients progress or lack of progress in relation to the stated goals. Outside trainings will also be utilized for staff needing additional training. Clinical Supervisor to review Treatment plans before being posted as completed. Clinical Supervisor and Director will be responsible. |
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 a review of client records on December 5 and 6, 2007 the facility failed to provide for measurable goals and objectives in 6 of 8 client records where aftercare plans were required. Client records # 15, 21, 23, 24, 27 and 28 contained incomplete aftercare plans.
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Plan of Correction
A training will be provided on after care planning which will include identifying and documenting measurable goals and objectives. Clinical Supervisor will review after care planning during clinical quality reviews to ensure compliance. Clinical Supervisor will be responsible. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records on December 5 and 6, 2007 the facility failed to provide for complete discharge summaries in 9 of 17 client records where required. The 'reasons for treatment' were consistently missing from client records # 14, 15, 16, 17, 18, 19, 20, 21 and 24.
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Plan of Correction
Clinical Supervisor will provide a training on including reasons for treatment when completing a discharge summary. The current form used to complete the discharge summary will be amended to include reasons for treatment. Clinical Supervisor and Director will be responsible. |