INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 21 through 22, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House 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 April 23, 2011.
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Plan of Correction
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs and an interview with the facility director, the facility failed to document whether the fire alarm or smoke detector was documented during each fire drill.
The findings include:
The fire drill logs were reviewed on March 21, 2011. Per regulation, a nonresidential facility shall set off a fire alarm or smoke detector during each fire drill. The fire drill log was reviewed for documentation of fire drills from the time period of February 2010 to February 2011. The facility failed to document on the fire drill logs that a smoke detector or fire alarm had been activated in ten out of twelve months. The fire drills documented on March 4, 2010, April 29, 2010, May 20, 2010, June 7, 2010, August, 13, 2010, September 2, 1010, October 21, 2010, November 19, 2010, December 1,2 010, January 27, 2011, and February 28, 2011 did not indicate whether the fire alarm or smoke detector was activated.
The facility director was interviewed on March 21, 2011, and confirmed there was no documentation on whether or not the fire alarm or smoke detector was not activated each month.
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Plan of Correction
The facility will assure that all documentation on the fire drill logs is completed and that the smoke detector or fire alarm is activated and documented. The Program Director and Health and Safety Captain will monitor the fire drills and documentation for compliance. |
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 on a review of fiscal documents presented at the time of the inspection, the facility failed to document an annual audit of financial activities for the year that ended December 31, 2009.
The findings included:
During the onsite licensing inspection conducted from March 21 through 22, 2011, the fiscal documents were reviewed. The certified public accountants dated and signed comments at the beginning of the fiscal document indicated that the document was not an audit. The letter from the accountant stated "...A review consists principally of inquiries of group personnel and analytical procedures applied to financial data. It is substantially less in scope than an audit in accordance with auditing standards generally accepted in the United States of America, the objective of which is the expression of an opinion regarding the consolidated financial statements taken as a whole. Accordingly we do not express such an opinion."
The documentation presented failed to meet the requirement for the annual financial audit.
This is a repeat citation from the licensing inspection conducted on April 1 through 2, 2010. The plan of correction for the April 1 through 2, 2010 inspection stated, "Discovery House will conduct an audit for FY 2010. We will submit a 2009 compellation review and an engagement letter for 2010 " . The responsible parties for this correction will be the Program Sponsor and the Program Director."
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Plan of Correction
Discovery House has conducted an audit for FY 2010. The compellation review and an engagement letter have been sent verifying the completion of this financial audit of fiscal activities for the year. The audit documentation will be sent to the Department of Health division of program licensure upon completion from the external accountant once possessed by Discovery House. 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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709.91(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 document 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 fourteen of fourteen records.
The findings Include:
Twelve records were reviewed March 22, 2011. Ten records were reviewed for compliance with the regulations. Ten records did not document personal histories that included all components of a personal history that are comprised 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. Specifically, patient records # 1,2, 3, 5, 6, 7, 8, 9, 10, and 11.
Record #1 - Client was admitted on 2-23-2011. The facility failed to document a personal history to include detail in the areas of family drug abuse history, educational history and military history.
Record #2 - Client was admitted on 8-16-2010. The facility failed to document a personal history to include educational history, military history, and sexual history.
Record #3 - Client was admitted on 8-30-2010. The facility failed to document a personal history to include employment/vocational history, educational history, and military history.
Record #5 - Client was admitted on 5-24-2010. The facility failed to document a personal history to include family drug abuse history, employment/vocational history, educational history, military history, recreational history, and sexual history.
Record #6 - Client was admitted on 8-24-2010. The facility failed to document a personal history to include family drug abuse history, employment/vocational history, educational history, and military history.
Record #7 - Client was admitted on 1-28-2011. The facility failed to document a personal history failed to include employment/vocational history, educational history, military history, and sexual history.
Record #8 - Client was admitted on 6-2-2010. The facility failed to document a personal history to include family history, legal history, employment/vocational history, educational history, military history, recreational history, and sexual history.
Record #9 - Client was admitted on 10-29-2010. The facility failed to document a personal history to include family drug abuse history, educational history, and military history.
Record #10 - Client was admitted on 10-6-2010. The facility failed to document a personal history to include family drug abuse history, legal history, educational history, military history, recreational history, and sexual history.
Record #11 - Client was admitted on 12-7-2010. The facility failed to document a personal history to include military history.
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Plan of Correction
Program Director and Clinic Supervisor will provide training to all staff on complete documentation of the patient's personal history. This documentation will include all components of the personal history which includes: 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. This process will be monitored by the Clinical Supervisor. Staff currently has been advised verbally and a comprehensive training will be conducted within 30 days.
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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, the facility failed to provide written documentation of the proposed type of support services, in the individual treatment and rehabilitation plans, in five of ten client records.
The findings include:
Twelve client records were reviewed on March 22, 2011. The individual treatment and rehabilitation plans were required to include documentation proposed type of support services in ten client records. The facility did not document proposed type of support services in client records # 2, 6, 9, 10, and 11.
Client # 2 was admitted on August 16, 2010. The individual treatment and rehabilitation plan was completed on September 9, 2010. There was no documentation of support services in the treatment plan.
Client # 6 was admitted on August 24, 2010. The individual treatment and rehabilitation plan was completed on September 9, 2010. There was no documentation of support services in the treatment plan.
Client # 9 was admitted on October 29, 2010. The individual treatment and rehabilitation plan was completed on November 24, 2010. There was no documentation of support services in the treatment plan.
Client # 10 was admitted on October 6, 2010. The individual treatment and rehabilitation plan was completed on October 7, 2010. There was no documentation of support services in the treatment plan.
Client # 11 was admitted on December 7, 2010. The individual treatment and rehabilitation plan was completed on January 5, 2011. There was no documentation of support services in the treatment plan.
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Plan of Correction
Program Director and Clinic Supervisor will provide training to clinical staff on ensuring that all patients are provided written documentation of the proposed type of support services in the individual treatment and rehabilitation plan. This will be monitored by the Clinical Supervisor. This staff has been advised verbally and a comprehensive training will be conducted within 30 days. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on review of the facility's policy and procedure manual the facility failed to include a policy that included procedures for clients who transfer to another program.
The findings include:
The facility policy and procedure manual was reviewed on March 21, 2011. Based on the information in the project's Discharge Procedures Policy created in December 2003 and modified in November 2008. The policy indicated:
Follow up contacts
Discovery House collected post discharge outcome information that included:
- Obtaining evaluation of the program by the patient
- Collecting clinical information that compared the current status of the patients to their status at discharge and is used to measure treatment effectiveness.
- Provides and opportunity for re-engagement or referral if necessary.
- When a patient abruptly terminated follow-up will take place within 72 hours post discharge
- Regular follow-up will be made either phone or mail dependent on the expressed preference of the patient and the completion of the appropriate release
- The patients primary counselor or a designee will be responsible for follow-up attempts
- All attempts will be documented in the patient record.
The policy failed to include when a client has been discharged and referred to an outside resource, the project should, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral.
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Plan of Correction
Discovery House has corrected policy under Referral and Transition Services and Case Coordination. This policy addresses when a client has been discharged and referred to an outside resource, the project should, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. |