INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 31, 2011 through November 2, 2011, 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.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, staff training records, and the Staffing Requirements Facility Summary Report, the facility failed to document HIV/AIDS and TB/STD training in one of one personnel record.
The findings include:
Ten personnel records were reviewed on October 31, 2011 Per regulation, staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. The facility failed to document training with the Department approved curriculum for HIV/AIDS and TB/STD in personnel records # 10.
Employee # 10 is a Physician's Assistant and was hired on March 25, 2009. A Department approved curriculum in HIV/AIDS and TB/STD training was due to be completed no later than March 25, 2011. Documentation of this training was not available at the time of the review, on October 31, 2011.
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Plan of Correction
Associate has been schedule to complete 6hrs Basic HIV and 4hrs TB,STD, and other health related topics on December 13th and 14th 2011. Program Director will monitor training hours on a quarterly basis to ensure compliance with required training. Program Director will be responsible and Corrective action date will be December 14th 2011. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the office belonging to counselor # 7 included a heater that was not permanently mounted or installed.
The findings include:
The physical plant inspection took place on on October 31,2 011. Counselor # 7's office was observed to have a heater that was not permanently mounted or installed. The director confirmed this finding.
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Plan of Correction
Heating unit was removed from the building immediately. A Alert was discussed during a team meeting which addressed 705.26(2) which states that heating units are not permitted in the facility. All associates signed off on the alert and reported their understanding. Program Director will continue to monitor during quarterly building inspections. This was completed on 11/16/11. |
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 the 2010 annual report during the onsite licensing inspection of October 31, 2011 through November 2,2 011, the facility failed to document a financial statement of income and expenses in the body of the report.
The findings include:
The annual report was reviewed during the licensing inspection. No financial statement of income and expenses was documented. The facility director confirmed that this was not included in the annual report. This is a repeat citation from the November 15, 2011 through November 17, 2011 licensing inspection.
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Plan of Correction
The financial statement of income and expenses will be included in the annual report and not as an insert. Program Director will be responsible for informing and working with our coorporate office to ensure this is implemented. This will be completed for the 2011 annual report.
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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 patient 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, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history and sexual history in thirteen of eighteen records.
The findings include:
Eighteen records were reviewed for compliance with the regulations. Thirteen records did not document personal histories that included all components of a personal history that are comprised of family drug abuse history, legal history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history, and sexual history. Specifically, patient records # 1, 2, 3, 4, 5, 6, 7, 12, 13, 14, 15, 16, and 19.
Record # 1 - Patient was admitted on 6-21-2011. The personal history failed to include information in the area of military history.
Record # 2 - Patient was admitted on 7-6-2011. The facility failed to document a personal history to include educational history, military history, and sexual history.
Record # 3 - Patient was admitted on 7-22-2011. The facility failed to document a personal history to include educational history and military history.
Record # 4 - Patient was admitted on 6-15-2011. The facility failed to document a personal history to include educational history, military history, and sexual history.
Record # 5 - Patient was admitted on 3-162011. The facility failed to document a personal history to include educational history and sexual history.
Record # 6 - Patient was admitted on 1-4-2011. The facility failed to document a personal history to include educational history, military history, and sexual history.
Record # 7 - Patient was admitted on 5-5-2011. The facility failed to document a personal history to include educational history, military history, and sexual history.
Record # 12- Patient was admitted on 9-19-2011. The facility failed to document a personal history to include sexual history.
Record # 13- Patient was admitted on 8-17-2011. The facility failed to document a personal history to include sexual history.
Record # 14- Patient was admitted on 9-30-211. The facility failed to document a personal history to include sexual history.
Record # 15- Patient was admitted on 9-12-2011. The facility failed to document a personal history to include sexual history.
Record # 16- Patient was readmitted on 9-29-2011. Patient has been a previous patient and the facility failed to complete a personal history to include family drug abuse history, legal history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history, and sexual history. The history that was in the record was completed 2-26-2009.
Record # 19 - Patient was admitted on 8-17-2011. The facility failed to document a personal history to include sexual history.
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Plan of Correction
A training will be provided to clinical staff by the Program Director and Clinical Supervisor which will focus on documenting Histories which include details of family history, legal history, employment/vocational history, education history, military history, recreational history, prior treatment, client perception of drug use, family drug abuse history and sexual history. This will take place within the next 30 days. Program Director and Clinical Supervisor will complete quarterly chart reviews to ensure compliance. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of patient records, the facility failed to document follow-up attempts according to the facility's policy and procedures in five of the six required records.
The findings include:
Nineteen patient records were reviewed on November 2, 2011 and November 3, 2011. Six of the nineteen patient records were discharged patients and required follow-up documentation. According to the facility's policy and procedures, if a patient abruptly terminates from the program a follow-up will be conducted within 72 hours post discharge. If a patient receives an outside referral, with patient consent, contact will be make within one week from the day the referral was to be completed. Regular follow-up is conducted at 14 and 30 days post discharge. Follow up was not documented in accordance to the facility's policy in patient records # 3, 4, 5, 6, and 8.
Record # 3 was admitted on 7-22-2011 and discharged on 8-19-2011. The patient transferred to another program and follow-up should have been conducted by 8-26-2011. The follow-up was documented late on September 12, 2011.
Record # 4 was admitted on 5-23-2011 and discharged on 7-18-2011. The first follow-up attempt was due on 8-1-2011 and the second follow-up attempt was due on 8-17-2011. The first follow-up attempt was documented on 8-17-2011 and the second follow-up attempt was documented on 8-31-2011. Both attempts were late.
Record # 5 was admitted on 3-16-2011 and discharged on 8-1-2011. The second follow-up attempt was due on 8-31-2011. The second follow-up attempt was documented late on 9-6-2011.
Record # 6 was admitted on 1-4-2011 and discharged on 5-9-2011. The second follow-up attempt was due on 6-9-2011. The second follow-up attempt was documented late on 6-22-2011.
Record # 8 was admitted on 4-26-2010 and discharged on 5-19-2011. The first follow-up attempt was due on 6-2-2011 and the second follow-up attempt was due on 6-19-2011. The first follow-up was documented late on 6-14-2011. The second follow-up was documented late on 6-24-2011.
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Plan of Correction
A Review of DHHA policy was completed on 11/16/11 with clinical staff. The review focused on follow up information which focused on time frames and content. This was completed by Program Director. Clinical Supervisor and Program Director will complete quarterly Chart reviews to ensure compliance. This was completed on 11/16/11. |