INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 13-14, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Licensure Programs. Based on the findings of the on-site 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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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 and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employee's #7 and #11 received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #7 was hired as a counselor on November 18, 2019 and was due to have the communicable disease trainings no later than November 18, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD trainings as of the date of the inspection.
Employee #11 was hired as a counselor on July 24, 2019 and was due to have the communicable disease trainings no later than July 24, 2020. The employee completed the HIV/AIDS training on January 6, 2021. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor or designee will monitor the completion of any and all required trainings including, TB/STD & HIV/AIDS.
The Clinic Director will work with the Clinical Supervisor and the respective staff members to schedule and complete all necessary trainings by April 28, 2021; due to training availability during COVID-19.
The Clinic Director will review the mandatory and time sensitive regulatory training requirements, with all staff, clinical and non-clinical. And will review with managers the need to ensure such is completed and recorded timely to ensure compliance to §704.11(c)(1).
Such will be reviewed by the Clinic/Facility Director as well on a regular basis.
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical site inspection, the facility failed to ensure fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company. The facility's three fire extinguisher's tags showed the last inspection was in 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 2/26/21 All fire extinguishers were inspected and updated as needed by fire protection company.
The Health and Safety Liaison for the Clinic will ensure all fire extinguishers are updated annually and make any necessary appointments with the local Fire Marshal to ensure full compliance to regulation §705.28(c)(3).
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from January through December 2020, the facility failed to document whether the fire alarm or smoke detector was operative during the drills in all reviewed fire logs.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Health and Safety Committee designee will utilize the existing H & S documents and ensure monthly completion of same, which includes a written fire drill record noting the: date, time, amount of time for evacuation, exit route used, number of persons engaged in the drill, at the location or source of the fire drill annunciation.
The Clinic Director will review the Health and Safety binder, on a regular basis, to note and ensure all Fire Drills are conducted and documented accordingly.
This process will be reviewed by the Clinic Director during an all staff meeting on March 30, 2021.
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715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on observations during methadone monitoring, the facility failed to verify the correct identity of a patient prior to administration of an agent in one client. It was observed that the nurse did not ask for the patient's identification number or dose prior to administering the methadone dose.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Nursing completed courses identified below3/16/21
Description: In concert with Acadia Healthcare CTC Division Policies surrounding Medication Management - Methadone 6.1.11
Description: In concert with Acadia Healthcare CTC Division Policies surrounding Medication Management - Methadone 6.1.11
1)Dispensing - Diversion Control.
2)Take-Home Medication & Diversion.
3)Document Storage and Destruction
In addition, there are acknowledgements for each policy that confirm you have read and understand each policy contained in this course.
Adherence to such will also be reviewed during an all staff meeting on March 30, 2021 and will continue to be part of all new nursing personnel on-boarding.
Monthly reviews of compliance will be conducted by the Clinic Director with the Charge Nurse and/or other nursing management personnel to ensure Take Home bottle verification continues to be completed and in compliance to expectations.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to ensure random urinalysis was conducted monthly in one out of seven patient records reviewed.
Patient #3 was admitted on May 6, 2019 and was still active at the time of the inspection. There was no documentation in the patient's record of an urinalysis being conducted in September 2020.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director provided a Medical Team in-service on 1/29/21 to review regulations and policy and procedures surrounding urine drug screen and the random schedule of same being conducted monthly in compliance with 715.14(a).
The Charge Nurse or designee will complete a review of the DSA report in the EMR on a monthly basis to insure drug screens are administered monthly and will complete an End of Month notation to support same.
The Clinic Director will review adherence to such on an End of Month basis
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715.15(d) LICENSURE Medication dosage
(d) A narcotic treatment program shall label all take-home medication with the patient 's name and the narcotic treatment program 's name, address and telephone number and shall package all take-home medication as required by Federal regulation.
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Observations
Based on observations during methadone monitoring, the facility failed to ensure take-home medication containers being returned were identified as the same containers previously given to the client. The nurse failed to inspect the labels of the take home bottles of one client when being returned.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Nursing completed courses identified below 3/16/21
1)Dispensing - Diversion Control
2)Take-Home Medication & Diversion.
3)Document Storage and Destruction.
In addition, there are acknowledgements for each policy that confirm you have read and understand each policy contained in this course.
Adherence to such will also be reviewed during an all staff meeting on March 30, 2021 and will continue to be part of all new nursing personnel on-boarding.
Monthly reviews of compliance will be conducted by the Clinic Director with the Charge Nurse and/or other nursing management personnel.
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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 patients with the two and a half hours of psychotherapy per month during the patient's first two years of treatment in one out of seven records reviewed.
Client #3 was admitted on May 6, 2019 and was still active at the time of the inspection. During the months of September through December 2020, there was no documentation that the client received any individual therapy sessions. In addition, in November and December 2020, the client received sixty minutes each month in group therapy.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinic Director and Clinical Supervisor completed a review of the Policy and licensure standard 715.19 (1) with the clinical team on 1/29/21
Reinforcement of CTC Divisional policies and protocols were set in place to include each counselor to complete an end of day counseling report to be submitted to the clinical supervisor. This will be reviewed during weekly supervision along with the Direct Service Analysis report that will be run weekly by the Clinical Supervisor. During these supervision meetings strengths and barriers will be identified and, as appropriate, shared with the team during clinical group supervision meetings.
The aforementioned processes and outcomes will be reviewed by the Clinic Director and Clinical Supervisor during weekly supervision and at the end of each month to ensure adequate psychotherapy hours are being offered to each patient.
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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 client records, the facility failed to document an annual evaluation of the patient in two out of seven client records reviewed.
Client #5 was admitted on June 17, 2019 and discharged on October 6, 2020. The annual evaluation was due no later than June 17, 2020; however, it was completed on June 30, 2020.
Client #6 was admitted on August 17, 2018 and was still active at the time of the inspection. The most recent annual evaluation was due no later than August 17, 2019; however, it was completed on October 8, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinic Director and Clinical Supervisor completed a review of the Policy and licensure standard 716.23(c) with the clinical team on 2/2/21
Reinforcement of CTC Divisional Protocols were reviewed. At the end of each day the Clinical Supervisor will prepare a list of services due that will be provided to each respective counselor to review and complete.
During weekly supervision meetings, counselors will bring along with them a copy of their respective weekly services due report from the EMR for discussion and review.
Barriers will be identified and resolutions established to ensure adherence to patient care and services; and will be shared during weekly group supervision sessions as needed and to the benefit of the clinical team on site.
The Clinic Director will review such on a monthly basis with the Clinical supervisor to ensure adherence to same.
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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 on a review of client records, the facility failed to document a psychosocial evaluation within the seven-day timeframe indicated in the facility's policy and procedures manual in five out of seven records reviewed.
Client #2 was admitted on February 19, 2020 and was still active at the time of the inspection. The psychosocial evaluation was due on February 26, 2020; however, it was completed on March 12, 2020.
Client #3 was admitted on May 6, 2019 and was still active at the time of the inspection. The psychosocial evaluation was due on May 13, 2019; however, it was completed on May 28, 2019.
Client #4 was admitted on March 20, 2019 and discharged on July 24, 2020. The psychosocial evaluation was due on March 27, 2019; however, it was completed on April 23, 2019.
Client #5 was admitted on June 17, 2019 and discharged on October 6, 2020. The psychosocial evaluation was due on June 23, 2019; however, it was not completed until July 23, 2019.
Client #7 was admitted on March 25, 2019 and discharged on February 27, 2020. The psychosocial evaluation was due on April 1, 2019; however, it was not completed until April 29, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director and Clinical Supervisor completed a review of the Policy and licensure standard 709.91(b)(6) with the clinical team on 2/8/21
Reinforcement of CTC Divisional Protocols were reviewed. At the end of each day the Clinical Supervisor will prepare a list of services due that will be provided to each respective counselor to review and complete.
During weekly supervision meetings, counselors will bring along with them a copy of their respective weekly services due report from the EMR for discussion and review.
Barriers will be identified and resolutions established to ensure adherence to patient care and services; and will be shared during weekly group supervision sessions as needed and to the benefit of the clinical team on site.
The Clinic Director will review such on a monthly basis with the Clinical supervisor to ensure adherence to same
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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 client records, the facility failed to ensure clients received counseling services according to their individual comprehensive treatment plans in six out of seven charts reviewed.
Client #1 was admitted on February 22, 2017 and was still active at the time of the inspection. The treatment plan, dated October 28, 2020, indicated two individual sessions per month. The record of service and progress notes indicated that received zero individual sessions in November 2020 and sixty minutes in December 2020.
Client #2 was admitted on February 19, 2020 and was still active at the time of the inspection. The treatment plan dated October 8, 2020 indicated one individual session and two group sessions per month. The client did not receive any group sessions in October 2020 and zero sessions in November and December 2020.
Client #3 was admitted on May 6, 2019 and was still active at the time of the inspection. The treatment plan dated July 29, 2020 indicated two hours of individual and 3 hours of group per month. In September, October, November and December 2020, the client did not receive any individual sessions. In addition, the client received sixty minutes of group therapy in each month in November and December 2020.
Client #5 was admitted on June 17, 2019 and discharged on October 6, 2020. The treatment plan, dated June 30, 2020, indicated two hours of individual and three hours of group therapy per month. The client received sixty minutes of individual therapy in June and August 2020.
Client #6 was admitted on August 17, 2018 and was still active at the time of the inspection. A treatment plan, dated August 18, 2020, indicated one individual and three group sessions per month. The client received zero group session in October and December 2020 and zero individual sessions in November 2020.
Client #7 was admitted on March 25, 2019 and discharged on February 27, 2020. The treatment plan dated March 25, 2019 indicated two hours of individual therapy and three hours of group therapy per month. The client received sixty minutes of individual therapy in August, September, October, and November 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director and Clinical Supervisor completed a review of the Policy and licensure standard 709.92(c) with the clinical team on 2/15/21
Reinforcement of CTC Divisional Protocols were reviewed. At the end of each day the Clinical Supervisor will prepare a list of services due that will be provided to each respective counselor to review and complete.
During weekly supervision meetings, counselors will bring along with them a copy of their respective weekly services due report from the EMR for discussion and review.
Barriers will be identified and resolutions established to ensure adherence to patient care and services; and will be shared during weekly group supervision sessions as needed and to the benefit of the clinical team on site.
The Clinic Director will review such on a monthly basis with the Clinical supervisor to ensure adherence to same.
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