INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 22-23, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.6(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 on a review of personnel records, the facility failed to document completion of core curriculum in clinical supervision training by the Clinical Director. The Clinical Director was promoted to the position on May 1, 2020 and as of the date of the inspection, had not completed the required training.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor shall complete a core curriculum in clinical supervision provided by the Department or shall receive prior approval from the Department.
Clinical Director will assist Clinical Supervisor with scheduling clinical supervision training
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of personnel files, the facility failed to document monthly meetings between the Clinical Director and his/her supervisors for the first six months of employment in that position. The Clinical Director was promoted to the position on May 1, 2020. There was no documentation of the meetings occurring at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will meet with Clinical Supervisor Director for monthly clinical supervision trainings.
Clinical Director will monitor trainings to assure clinical supervisor is receiving required trainings.
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel files, the facility failed to document that each counselor met both the education and experiential qualifications for the position.
Employee #5, whom was hired as a counselor on September 1, 2020, did not meet the educational requirements to be a counselor. At the time of the hire, the employee did not have a qualifying degree.
The findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the January 30, 2020 licensing inspection.
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Plan of Correction
Counselor position will be reduced to a Counselors Assistant Position. Counselor will obtain 1 year of clinical experience (a minimum of 1,820 hours) in a drug and alcohol setting before eligibility to qualify for a full counselor position. The individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues and work towards obtaining a CADC.
Clinical Director will assure all clinical positions meet qualifications for a counselor position before the hiring process. Clinical Director will refer to the Department of Drug and Alcohol Program' counselor for clarity of qualifications |
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 files and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employee's # 6, 7, 8 and 9 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 #6 was hired as a counselor on March 4, 2019 and was due to have the communicable disease trainings no later than March 4, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #7 was hired as a counselor on January 21, 2019 and was due to have the communicable disease trainings no later than January 21, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #8 was hired as a counselor on October 2, 2019 and was due to have the communicable disease trainings no later than October 2, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #9 was hired as a counselor on December 23, 2019 and was due to have the communicable disease trainings no later than December 23, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the January 30, 2020 licensing inspection.
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Plan of Correction
Clinical Supervisor will assure new counselors are scheduled and attend a minimum of 6 hours of HIV/AIDS training, minimum of 4 hours tuberculosis, sexually transmitted diseases and other health related topics training using a department approved curriculum within their first 90 days of employment. 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. Clinical Supervisor will be required to submit a sign off sheet from each new counselor indicating they have completed the required training to Clinic Director in allotted time required. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to maintain counselor caseloads within the limits set by the regulation for employee #'s 3, 5, 6, 8, 9, 10, 11 and 12.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor's caseload is divided by the FTE.
Employee #3 was reported to have 32 hours per week devoted to their 35 clients on their caseload. The FTE caseload calculation is as follows: 32/40 = .8 (FTE); 35/.8 = 43.75, which equals a client/counselor ratio of 44:1.
Employees #5, 6, 8, 9, 10, 11 and 12 were reported to each have 35 hours per week devoted to their 35 clients on their caseload. The FTE caseload calculation is as follows: 35/40 = .875 (FTE); 35/.8 = 40, which equals a client/counselor ratio of 40:1.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the January 30, 2020, November 21, 2018 and December 6, 2017 licensing inspections.
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Plan of Correction
Clinic Supervisor will redistribute clients to ensure each caseload is a 35:1 ratio for active patients to counselor.
Clinic Director will monitor and maintain a qualified pool of potential counselors to assure facility maintains a 35:1 ratio.
The Clinic Director will continue to work with Human Resources Business Partner in the recruitment and hiring of appropriate staff for the project and to ensure that the FTE counselor caseload for counseling in an outpatient program does not exceed 35:1 active patients.
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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 on a physical plant inspection, it was observed that the facility failed to ensure the safety and well-being of clients, staff, and visitors as evidenced by the following:
1) The roof was leaking into the lobby and front hallway area. There were five containers catching the water. Clients and staff had to walk through the area in order to access counselor and physician offices.
2) In the back hallway a molding strip on the floor was missing screws causing it to be loose and raised off the floor. It caused a tripping hazard.
3) In the back bathroom used by buprenorphine clients, a two square foot area at the bathroom's door was very soft when stepped on. In addition, the area had missing and damaged flooring which caused a tripping hazard.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Discovery House Harrisburg will be moving to a new location 2/22/2021. The facility has been completely renovated. Physical plant is in excellent condition. Maintenance will be scheduled for cleaning daily. Clinic Director will monitor weekly. |
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 on a review of client records, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. In client record #7, a progress note dated April 23, 2020 stated that a telehealth session between the counselor and client was overheard by two other counselors that were occupying two nearby offices.
Client #7 was admitted on June 30, 2017 and was discharged on April 28, 2020.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Discovery House Harrisburg will be moving to a new location 2/22/2021. The facility has been completely renovated. Physical plant is in excellent condition to ensure privacy walls are installed and counseling sessions will not be heard outside of counseling and/or group rooms. |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical site inspection, the facility failed to maintain each bathroom in a clean manner at all times. The bathroom lobby used by clients was observed to be dirty with paper products on the floor and the baby changing table had a brown liquid spilled on it.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Discovery House Harrisburg will be moving to a new location 2/22/2021. The facility has been completely renovated. Physical plant is in excellent condition.
Building maintenance will be scheduled to clean building daily.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel files, the facility failed to ensure all personnel are instructed in the use of the fire extinguisher upon staff employment. Employee #4 was hired as a counselor on November 9, 2020. Fire extinguisher training did not occur until December 21, 2020.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Fire extinguisher training checklist has been added for new staff employees. An employee signature acknowledgement 16.1 Health & Safety form has been established and an employment checklist will be completed on the first day of employment by the Clinic Director and the Health and Safety Captain. The Clinic Director will review the checklist for compliancy quarterly. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel files, the facility failed to ensure all personnel are trained to perform assigned tasks during emergencies. Employee #4 was hired as a counselor on November 9, 2020. Emergency training did not occur until December 21, 2020.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Fire extinguisher training checklist has been added for new staff employees. An employee signature acknowledgement 16.1 Health & Safety form has been established and an employment checklist will be completed on the first day of employment by the Clinic Director and the Health and Safety Captain. The Clinic Director will review the checklist for compliancy quarterly. |
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 the review of the February 2020 through November 2020 fire drill logs, the facility failed to include all required information. The February 2020 and March 2020 fire drill logs did not include if the fire alarm/smoke detector was operational at the time of the drill. In addition, The October 2020 fire drill log did not indicate the length of time it took for evacuation.
The findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the January 30, 2020 and November 21, 2018 licensing inspections.
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Plan of Correction
Fire drills will developed and maintained by 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. Clinical Director will review and monitor all fire drill reports.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based upon the review of the policy and procedures manual, the facility failed to provide documentation that the project director annually updated the manual.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Directors will assure the policy and procedures manual documentation will be updated annually. Clinic Director will monitor quarterly. |
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.
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent to release information form prior to disclosing information in six out of fifteen records.
Client #3 was admitted on June 21, 2017 and was still active at the time of the inspection. There was no documentation of a consent form for information released to the funding source. Facility staff confirmed that billing had occurred.
Client #6 was admitted on April 29, 2020 and discharged on August 20, 2020. A consent form for the funding source was signed by a witness on April 28, 2020 and did not contain the client's signature. Documentation in the client's record showed contact was made with the funding source on April 27, 2020.
Client #7 was admitted on June 30, 2017 and discharged on April 28, 2020. There was no documentation of a consent form for information released to two different funding sources. The record showed contact was made to the one funding source on February 21, 2020, March 16, 2020 and May 4, 2020. Contact with the second funding source occurred on March 11, 2020.
Client #9 was admitted on May 8, 2020 and was still active at the time of the inspection. There was no documentation of a consent form for information released to the funding source. Facility staff confirmed that billing had occurred.
Client #10 was admitted on April 9, 2020 and discharged on December 1, 2020. There was no documentation of a consent form for information released to the funding source. Facility staff confirmed that billing had occurred. In addition, a progress note dated November 19, 2020 stated that a staff member attempted to contact the client via telephone. The call was answered by a person other than the client. The staff person provided information to the person on the phone to the client's participation in treatment. There was no consent on file for this information to be released.
Client #11 was admitted on April 30, 2020 and was still active at the time of the inspection. There was no documentation of a consent form for information released to the funding source. Facility staff confirmed that billing had occurred.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the January 30, 2020 licensing inspection.
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Plan of Correction
The Clinical Supervisor will present a staff training on Confidentiality of Patient records 2-11-2021 to include obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record. The training will include consents must be in writing and include, but not be limited to: (3) Purpose of disclosure.
Clinic Director will assure all staff attends the mandatory training. Clinical Director and Clinical Supervisor will review patient records monthly to assure compliance.
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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 must 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, the facility failed to keep disclosure of client identifying information within the limited established by 4 Pa. Code 255.5(b) for releases of information in five out of fifteen client records. In addition, one client out of fifteen was missing specific information to be released on the consent form.
Client #4 was admitted on October 14, 2020 and was still active at the time of the inspection. Two consent forms to a medical facility and funding source, dated October 27, 2020 and November 3, 2020 respectively, did not include what information was permitted to be released.
Client #5 was admitted on April 22, 2016 and was still active at the time of the inspection. A consent to release form dated May 20, 2020 to probation allowed for the release of medical history, current dose level, lab work results and dose history.
Client #11 was admitted on April 30, 2020 and was still active at the time of the inspection. Two consent to release forms, both dated May 22, 2020 to two different parole officers allowed for the release of treatment plan and drug test results.
Client #12 was admitted on July 1, 2020 and was still active at the time of the inspection. Four consent to release forms, all dated July 1, 2020 allowed for the release of treatment plans. Three of the forms were to funding sources and one was to a government agency.
Client #14 was admitted on February 20, 2020 and was still active at the time of the inspection. Two consent to release forms, both dated February 20, 2020 to a government agency and funding source permitted release of treatment plans.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the January 30, 2020 licensing inspection.
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Plan of Correction
The Clinical Supervisor will present a staff training on Confidentiality of Patient records to include obtaining informed and voluntary consent from the client for the disclosure of information. The training will focus on assuring to stay in the boundaries set by 255.5(b). The active patients that are listed in this deficiency will sign a revised consent form.
Clinic Director will assure all staff attends the mandatory training. Clinical Director and Clinical Supervisor will review patient records monthly to assure compliance.
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709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to obtain a dated signature by the client on consent to release information forms in two out of fifteen records.
Client #6 was admitted on April 29, 2020 and discharged on August 20, 2020. Six consent to release information forms were signed by a witness on April 28, 2020 but did not contain a dated client signature. The consent forms were all for other treatment facilities.
Client #12 was admitted on July 1, 2020 and was still active at the time of the inspection. Four consent to release information forms were signed by a witness on July 1, 2020 but did not contain a dated client signature. Three consent forms were for the funding source and one was for a government agency.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will present a staff training on Confidentiality of Patient records 2-11-2021 to include obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record. The training will include consents must be signed and dated.
Clinic Director will assure all staff attends the mandatory training. Clinical Director and Clinical Supervisor will review patient records monthly to assure compliance.
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709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights in client record #'s 2, 11 and 12.
Client #2 was admitted on July 17, 2020 and was still active at the time of the inspection.
Client #11 was admitted on April 30, 2020 and was still active at the time of the inspection.
Client #12 was admitted on July 1, 2020 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the January 30, 2020 licensing inspection.
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Plan of Correction
The Clinical Supervisor will present a staff training on Clients Rights and document written acknowledgement 2-18-2021. All patients listed in this deficiency will sign a patients' rights acknowledgement.
Clinic Director will assure all staff attends the mandatory training. Clinical Director and Clinical Supervisor will review patient records monthly to assure compliance.
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715.7(b) LICENSURE Dispensing or Administering Staffing
(b) Dispensing time shall be prorated for patient census. There shall be sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.
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Observations
Based on observation of methadone dosing, the facility failed to ensure that all patients are medicated within fifteen minutes of arrival at the dispensing area. In speaking with patients in a line of nine patients waiting to be dispensed medication, the patients confirmed that there are times in the last month that the wait exceeded fifteen minutes. Facility staff confirmed the wait time has exceeded fifteen minutes in the past.
The findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Nurse Manager will monitor dispensing time to assure all patients are medicated within 15 minutes of arrival at the dispensing area. Director will monitor dosing report to assure patients are being medicated within 15 minutes of arrival at the dispensing area. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of client records, the facility failed to verify the patient's identity and obtain an emergency contact in six out of fifteen records.
Client #1 was admitted on April 8, 2002 and was still active at the time of the inspection. There was no emergency contact in the record.
Client #2 was admitted on July 17, 2020 and was still active at the time of the inspection. There was no emergency contact in the record.
Client #7 was admitted on June 30, 2017 and was discharged on April 28, 2020. There was no emergency contact in the record.
Client #10 was admitted on April 9, 2020 and discharged on December 1, 2020. There was no emergency contact in the record.
Client #11 was admitted on April 30, 2020 and was still active at the time of the inspection. There was no emergency contact in the record.
Client #12 was admitted on July 1, 2020 and was still active at the time of the inspection. There was no verification of the patient's identity in the record.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the January 30, 2020 licensing inspection.
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Plan of Correction
The Clinic Director and Clinical Supervisor will complete a training on verification on the patients individual identity, including name, address, date of birth, emergency contact and other identifying data prior to administration of an agent 2/18/2021. All information from patients in deficiency will be obtained. The Clinic Supervisor will monitor weekly for new admissions. The Clinic Director will monitor quarterly to assure compliance. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on the review of patient records, the facility failed to obtain a signed consent form prior to administering treatment to the patient in one out of five records.
Client #2 was admitted on July 17, 2020 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will present a staff training on Consent to treat with methadone prior to any administering of medication. The client listed in this deficiency will sign a consent to treat as well as all new clients will sign before they are administered any medication. There will be procedures put in place to include a staff sign off sheet that will be reviewed for each new patient daily by the Clinical Supervisor.
Clinic Director will assure all staff attends the mandatory training. Clinical Director and Clinical Supervisor will review new patient records weekly to assure compliance.
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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 observation of methadone medication dispensing, the facility failed to follow their policy and procedures manual for identifying of a patient prior to administration of an agency. The policy and procedure manual section 6.1 (7) states "dosage shall be verified by the patient to the nurse and confirmed with the current dose order before preparing". During observation, nine patients did not have their dose verified prior to administering of an agent. In addition, the 6.1.1 (7)(d) states "Patients will present at the dispensing window without hats or sunglasses". During observation, eight patients were not asked to remove their hats prior to dosing.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinic Director and Nurse Supervisor will complete a training on Policy 6.1 "Dispensing of Medication" on 02/19/2021. The Nurse Supervisor will observe dispensing weekly to ensure compliance in this area and address non-compliance during individual supervision |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of client records, the facility failed to maintain an onsite photograph of each patient in two out of fifteen records.
Client #11 was admitted on April 30, 2020 and was still active at the time of the inspection.
Client #14 was admitted on February 20, 2020 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor shall maintain onsite photographs of each patient which includes the patient 's name and birth date as part of the admission process. The narcotic treatment program shall update the photograph every 3 years. Clinic Director will monitor admission process to assure patient photographs are present in charts.
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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 observation of methadone medication dispensing, the facility failed to ensure that the take-home bottles being returned were the same bottles given to the patient previously by checking the name and date on the label. The facility's policy and procedure manual 6.2 states "Patients taking medication doses home for unsupervised dosing are expected to return the take-home bottle, label intact, the next scheduled day for onsite CTC dosing. One patient's bottles were observed to not be checked.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director and Nurse Supervisor will complete a training on Policy 6.1 "Dispensing of Medication" on 02/19/2021. The Nurse Supervisor will observe dispensing weekly to ensure compliance in this area and address non-compliance during individual supervision. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on observation of methadone medication dispensing, the facility failed to ensure each patient was observed when ingesting the agent. The facility's policy and procedure manual states "the patient will ingest the medication in front of the dispensing nurse and will speak with the dispensing nurse prior to leaving the dispensing area to minimize the possibility of medication diversion". One patient was observed to not speak prior to leaving the dispensing area.
The findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the January 30, 2020 licensing inspection.
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Plan of Correction
The Clinic Director and Nurse Supervisor will complete a training on Policy 6.1 "Dispensing of Medication" on 02/19/2021. The Nurse Supervisor will observe dispensing weekly to ensure compliance in this area and address non-compliance during individual supervision. |
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 patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month in five out of fifteen records.
Client #6 was admitted on April 29, 2020 and discharged on August 20, 2020. The patient received one hours of therapy in May 2020, thirty minutes in June 2020 and 90 minutes in July 2020.
Client #9 was admitted on May 8, 2020 and was still active at the time of the inspection. The patient received two hours of therapy in June 2020, ninety minutes in August 2020, and two hours in September 2020.
Client #10 was admitted on April 9, 2020 and discharged on December 1, 2020. The patient received two hours of therapy in September 2020.
Client #14 was admitted on February 20, 2020 and was still active at the time of the inspection. The patient received thirty minutes of therapy in June 2020, sixty minutes in July 2020 and no documentation of therapy sessions in August through December 2020.
Client #15 was admitted on December 5, 2019 and was still active at the time of the inspection. The patient received ninety minutes of therapy in September 2020, thirty minutes in October 2020, ninety minutes in November 2020 and sixty minutes in December 2020.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the January 30, 2020 licensing inspection.
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Plan of Correction
The Clinical Supervisor and Lead Counselor will make every effort to ensure each patient are provided with 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 and/or additional psychotherapy shall be provided as dictated by ongoing assessment of the patient by conducting monthly ongoing monitoring during quality record reviews.
The Clinical Services Coordinator will conduct a meeting with Clinical Supervisor bi-weekly to ensure patients are receiving the appropriate psychotherapy per month requirements.
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715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of client records, the facility failed to transfer patient files to the new treatment facility in one out of one record.
Client #7 was admitted on June 30, 2017 and was transferred to another treatment facility on April 28, 2020.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinic Supervisor will have a training on written transfer policies and procedures to transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient and a transfer acknowledgement form has been completed.
The Clinical Supervisor will review charts monthly to ensure policies are being maintained. The Clinical Supervisor will address non-compliance in this area during individual supervision
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of client records, the facility failed to document an annual physical examination in one out of eight records.
Client #1 was admitted on April 8, 2002 and was still active at the time of the inspection. The annual physical examination was due no later than April 8, 2020; however, it was completed on April 17, 2020.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Nurse Manager will collaborate with the Clinical Supervisor to ensure the Medical Director is aware of upcoming patient physical examinations to review, date, and sign at the beginning of each month.
The Clinic Director will meet with the Nurse Manager and Clinical Supervisor quarterly to assure this procedure is being maintained.
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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 the review of client records, the facility failed to document an annual clinical evaluation in one out of eight records.
Client #1 was admitted on April 8, 2002 and was still active at the time of the inspection. The annual clinical evaluation was due no later than April 8, 2020; however, it was completed on June 4, 2020.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Nurse Manager will collaborate with the Clinical Supervisor to ensure the Medical Director is aware of upcoming patient annual evaluations to review, date, and sign at the beginning of each month.
The Clinic Director will meet with the Nurse Manager and Clinical Supervisor quarterly to assure this procedure is being maintained.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document a consent to treat with buprenorphine in two out of five records.
Client #11 was admitted on April 30, 2020 and was still active at the time of the inspection.
Client #12 was admitted on July 1, 2020 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will do a training/review on intake and admission process. The Clinical Supervisor will conduct peer reviews as well as quarterly checks to ensure procedures are being maintained.
The Clinic Supervisor will update the Clinic Director weekly on intake and admission process.
. "Ongoing compliance will be monitored during quality record reviews. The Clinical Supervisor will address non-compliance in this area during individual supervision. Continued non-compliance will be addressed via the EIP process."
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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, the facility failed to complete an individual treatment plan, document the treatment plan was developed with the client and/or complete the individual treatment plan within the thirty day timeframe outline in the facility's policy and procedure manual in seven out of fifteen clients.
Client #2 was admitted on July 17, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than August 17, 2020; however, it was not completed until September 21, 2020 and did not include a dated client signature.
Client #6 was admitted on April 29, 2020 and discharged on August 20, 2020. A comprehensive treatment plan was completed on May 7, 2020. The treatment plan did not include a dated client signature.
Client #9 was admitted on May 8, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than June 8, 2020; however, it was not completed until June 18, 2020.
Client #10 was admitted on April 9, 2020 and discharged on December 1, 2020. The comprehensive treatment plan was due no later than May 9, 2020; however, it was not completed until June 19, 2020.
Client #11 was admitted on April 30, 2020 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than May 30, 2020; however, it was not completed until June 9, 2020 and did not include a dated client signature.
Client #12 was admitted on July 1, 2020 and was still active at the time of the inspection. A completed treatment plan was due no later than August 1, 2020; however, there was no documentation of a treatment plan being completed at the time of the inspection.
Client #14 was admitted on February 20, 2020 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than March 20, 2020; however, it was not completed until March 30, 2020 and did not include a dated client signature.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will do a training/review on individual treatment plans to include what written documentation is needed within the treatment plan, how frequent a patient should obtain services, and what type of service is required.
The Clinical Supervisor will conduct peer reviews as well as quarterly checks to ensure procedures are being maintained. The Clinic Supervisor will update the Clinic Director quarterly on treatment plan compliance.
. "Ongoing compliance will be monitored during quality record reviews. The Clinical Supervisor will address non-compliance in this area during individual supervision. Continued non-compliance will be addressed via the EIP process."
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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, the facility failed to document type and frequency of treatment services in the treatment plan in seven out of thirteen records.
Client #2 was admitted on July 17, 2020 and was still active at the time of the inspection. A comprehensive treatment plan dated September 21, 2020 did not include type and frequency of treatment.
Client # 4 was admitted on October 14, 2020 and was still active at the time of the inspection. A comprehensive treatment plan dated November 2, 2020 did not specify frequency for specific types of counseling.
Client #5 was admitted on April 22, 2016 and was still active at the time of the inspection. A treatment plan dated October 27, 2020 did not specify frequency for specific types of counseling.
Client #6 was admitted on April 29, 2020 and was discharged on August 20, 2020. A treatment plan dated May 7, 2020 did not specify the type of counseling sessions.
Client #9 was admitted on May 8, 2020 and was still active at the time of the inspection. A comprehensive treatment plan dated June 18, 2020 did not specify frequency of specific types of counseling.
Client #13 was admitted on September 17, 2014 and discharged on April 8, 2020. A treatment plan dated March 24, 2020 did not specify the frequency for specific types of counseling.
Client #14 was admitted on February 20, 2020 and was still active at the time of the inspection. A comprehensive treatment plan dated March 30, 2020 did not indicate type and frequency of treatment.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the November 28, 2018 and January 30, 2020 licensing inspections.
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Plan of Correction
The Clinical Supervisor will do a training/review on individual treatment plans to include what written documentation is needed within the treatment plan, how frequent a patient should
obtain services, and what type of service is required.
The Clinical Supervisor will conduct peer reviews as well as quarterly checks to ensure procedures are being maintained.
The Clinic Supervisor will update the Clinic Director quarterly on treatment plan compliance.
"Ongoing compliance will be monitored during quality record reviews. The Clinical Supervisor will address non-compliance in this area during individual supervision. Continued non-compliance will be addressed via the EIP process." |
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, the facility failed to document treatment plan updated within the regulatory timeframe in eight out of fifteen records. The facility's policy and procedure manual required a treatment plan update to be completed at a minimum of every sixty days.
Client #1 was admitted on April 8, 2002 and was still active at the time of the inspection. A treatment plan update was completed on August 7, 2020 and the next update was due no later than October 7, 2020; however, the next update was completed on December 2, 2020.
Client #3 was admitted on June 21, 2017 and was still active at the time of the inspection. A treatment plan update was completed on June 22, 2020 and the next update was due no later than August 22, 2020; however, there was no update documented in the record at the time of the inspection.
Client #9 was admitted on May 8, 2020 and was still active at the time of the inspection. A treatment plan update was completed on July 2, 2020 and the next update was due no later than September 2, 2020; however, the next update was completed on October 16, 2020.
Client #10 was admitted on April 9, 2020 and was discharged on December 1, 2020. A comprehensive treatment plan was completed on June 19, 2020 with an update due no later than August 19, 2020; however, the next update was completed on October 28, 2020.
Client #11 was admitted on April 30, 2020 and was still active at the time of the inspection. A comprehensive treatment plan was completed on June 9, 2020 with an update due no later than August 9, 2020; however, the next update was completed on October 26, 2020.
Client #12 was admitted on July 1, 2020 and was still active at the time of the inspection. A comprehensive treatment plan was to be completed within 30 days of admission and updates every sixty days. There was no documentation of any treatment plan updates in the client's record.
Client #13 was admitted on September 17, 2014 and discharged on April 8, 2020. A treatment plan update was completed on January 7, 2020 and the next update was due no later than March 7, 2020; however, there next update was completed on March 24, 2020.
Client #15 was admitted on December 5, 2019 and was still active at the time of the inspection. A treatment plan update was completed on June 5, 2020 and the next update was due no later than August 5, 2020; however, the next update was completed on October 23, 2020.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the January 30, 2020 licensing inspection.
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Plan of Correction
The Clinical Supervisor will do a training/review on individual treatment plans to include what written documentation is needed within the treatment plan, how frequent a patient should
obtain services, and what type of service is required.
The Clinical Supervisor will conduct peer reviews as well as quarterly checks to ensure procedures are being maintained.
The Clinic Supervisor will update the Clinic Director quarterly on treatment plan compliance.
"Ongoing compliance will be monitored during quality record reviews. The Clinical Supervisor will address non-compliance in this area during individual supervision. Continued non-compliance will be addressed via the EIP process."
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709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical site inspection, the facility failed to display the operational hours viewable to the general public.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Discovery House Harrisburg will be moving to a new location 2/22/2021. The facility has been completely renovated. Physical plant is in excellent condition.
The hours of project operation shall be displayed conspicuously to the general public.
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