INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on January 5-6, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Discovery House HA was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.7(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 the experiential qualifications for the position.
Employee #1 was hired as a counselor on May 3, 2021 and was still in that position at the time of the inspection. The employee does not have the one-year clinical experience required with a qualifying bachelor's degree.
This is a repeat citation from January 30, 2020, December 23, 2020 and the May 20, 2021 licensing inspections.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee #1 will obtain 1 year of clinical experience in a drug and alcohol setting before eligibility to qualify for a full counselor position. Clinical Supervisor will provide close supervision weekly. Counselor assistant's training plan will address goals to achieve counseling competency in chemical dependency issues and work toward obtaining CADC.
Clinic Director will ensure all clinical positions meet the qualifications for a counseling position before hiring. Clinic Director will refer to the Dept. of Drug and Alcohol to ensure new hires meet those qualifications. |
704.8(c) LICENSURE Full Caseload Assignment
704.8. Qualifications for the position of counselor assistant.
(c) In addition to training, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level.
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Observations
Based on a review of personnel files, the facility failed to document a positive assessment for a counselor assistant prior to the employee receiving a full caseload.
Employee #2 was hired on September 1, 2020 and was still in that position at the time of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor has completed a positive assessment of the counselor assistant's skills 2/14/22. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on the review of personnel records, the facility failed to show supervision for a counselor assistant based upon their qualifying education.
Employee #2 was hired on September 1, 2020 as a counselor and was reassigned to a counselor assistant position on January 11, 2021. The employee's bachelor's degree is non-qualifying therefore they must receive supervision as an employee with a high school diploma. At the time of the inspection, there was no documentation of close supervision had been provided during the months of June, July, August and December 2021.
This is a repeat citation from the May 20, 2021 licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will provide and document close supervision of the counselor assistant. Counselor assistant will continue to work toward obtaining her CADC through the PCB. Progress will be documented during supervision.
Clinical Supervisor will provide updates to the Clinic Director. Clinic Director will review supervision notes to ensure follow through. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on the review of personnel records, the facility failed to show documentation that a counselor assistant was working toward counselor status.
Employee #2 was hired on September 1, 2020 as a counselor and reassigned as a counselor assistant on January 11, 2021.
This is a repeat citation from the May 20, 2021 licensing inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
During supervision, the counselor assistant will provide weekly updates to the Clinical Supervisor that they are working toward counselor status. This will include training completion and receipt of college transcripts for review.
Clinical Supervisor will provide weekly updates to the Clinic Director regarding the counselor assistant's progress toward becoming a counselor. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on the review of patient records, the facility failed to document a complete consent to release information form which included a purpose of disclosure in one out of eight records reviewed.
Patient #7 was admitted on August 13, 2021 and was still active at the time of the inspection. The release of information form dated August 13, 2021 to an emergency contact listed "other" as the purpose without specifying another purpose.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors completed training 1/20/22 with clinical staff on the completion of releases of information. Training included five points that can be released, purpose and length of ROI's
Clinical Supervisors and Clinic Director will review release of information completion weekly to ensure compliance. |
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 medication administration, the facility failed to follow their policy and procedures manual in regard to administration of medication. Section 6.1.1 of the policy and procedures manual requires patients to speak to the nurse assuring that medication has not been diverted. One patient was not asked to speak prior to leaving the dispensing area.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Nurse Manager and Clinic Director completed training with dispensing nurses, reviewing policies and procedures regarding the administration of medication to ensure all Patients are asked to speak prior to leaving the dispensing area.
Nurse Manager and/or Clinic Director will will monitor/observe dosing weekly to ensure we are following our policies and procedures for administering medication. |
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 patient records, the facility failed to document an annual clinical evaluation in one out of three applicable records reviewed.
Patient #2 was admitted on November 25, 2020 and was still active at the time of the inspection. The annual clinical evaluation was due no later than November 25, 2021; however, there was no documentation of a clinical evaluation in the patient's record.
This is a repeat citation from the December 2, 2020 and May 20, 2021 licensing inspections.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisors will complete training/review of services due timeframes and completing services within timeframes. Training will also include process for completing annual clinical evaluations.
Clinical Director and Clinic Supervisors will review Pt charts and counselor to-do lists weekly to ensure services are being completed properly and within timeframes. |
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 patient records, the facility failed to complete an individualized treatment plan or complete the individual treatment plan within the thirty-day timeframe outlined in the facility's policy and procedure manual in four out of five applicable records.
Patient #4 was admitted on August 6, 2021 and was still active at the time of the inspection. The comprehensive treatment plan was due September 6, 2021; however, it was not completed until September 10, 2021.
Patient #5 was admitted on August 4, 2021 and was still active at the time of the inspection. There was no documentation of a treatment plan in the patient's record.
Patient #6 was admitted on July 22, 2021 and was still active at the time of the inspection. There was no documentation of a treatment plan in the patient's record.
Patient #8 was admitted on July 30, 2021 and was still active at the time of the inspection. There was no documentation of a treatment plan in the patient's record.
This is a repeat citation from the December 23, 2020 and May 20, 2021 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisors will complete a training will all clinical staff regarding timeframes for services due, i.e. initial treatment plans due 30 days following admission to treatment.
Clinic Director and Clinical Supervisors will review all admissions to ensure the initial treatment plan has been added and completed within 30 days of admission. |
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 patient records, the facility failed to document type and/or frequency of counseling services in the treatment plan in six out of eight records reviewed. The treatment plans did not specify frequency for each type of counseling service.
Patient #1 was admitted on December 18, 2020 and was still active at the time of the inspection. Treatment plan was dated December 9, 2021.
Patient #2 was admitted on November 25, 2020 and was still active at the time of the inspection. The treatment plan was dated November 17, 2021.
Patient #4 was admitted on August 6, 2021 and was still active at the time of the inspection. The treatment plan was dated November 29, 2021.
Patient #5 was admitted on August 4, 2021 and was still active at the time of the inspection. The treatment plan was dated December 2, 2021.
Patient #7 was admitted on August 31, 2021 and was still active at the time of the inspection. The treatment plan was dated December 1, 2021.
Patient #8 was admitted on July 30, 2021 and was still active at the time of the inspection. The treatment plan was dated November 30, 2021.
This is a repeat citation from the November 28, 2018, January 30, 2020, December 23, 2020 and May 20, 2021 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisors will complete a training with clinical staff regarding the completion of and documenting the type and frequency of clinical services being provided.
The Clinical Supervisors will review treatment plan completion daily to ensure procedures are being met and maintained.
Clinic Director will do weekly spot checks on treatment plans to ensure compliance. |