INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25-27, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on April 22, 2009.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records and conversation with the facility director, the facility failed to provide documentation demonstrating the project director met the qualifications.
The findings included:
Five personnel records were reviewed on March 25-16, 2009. The personnel record for Employee #1 did not contain any information showing what the qualifications would be to determine compliance. Instead, the personnel record only contained training certificates for the past three years.
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Plan of Correction
The qualifications for the position of project director will be forwarded to the clinic by the project director to be kept on file as proof of meeting qualifications for this position. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to ensure the instruction in the use of fire extinguishers upon employment in two of two personnel records.
The findings include:
Five personnel records were reviewed on March 26, 2009. Two were required to document training of fire extinguisher use upon employment. Employees # 4 and 5 were hired November 3, 2008. Employee # 4 received the fire extinguisher instruction on March 20, 2009 and employee # 5 received this instruction on March 23, 2009, both more than four months after employment began.
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Plan of Correction
The director will instruct all staff in the use of the fire extinguishers within 7 days of staff employment. Additionally, a checklist has been developed for all new associate charts, with the item of instruction of fire extinguishers on it, that will be audited by the program manager and director after each new hire. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 the review of personnel records, the facility failed to ensure the training to perform assigned tasks during emergencies in two of two personnel records no later than seven days from the start of their employment.
The findings include:
Five personnel records were reviewed on March 26, 2009. Two were required to show this training within seven days of employment. Employees # 4 and 5 were hired November 3, 2008. Employee # 4 received emergency training on March 20, 2009 and employee # 5 received this training on March 23, 2009, both more than four months following the commencement of their employment.
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Plan of Correction
The director will train all staff on all shifts to perform assigned tasks during emergencies, such as what to do in the case of a fire. A checklist for all new associate hires will include this specific item on it, and the checklist will be audited within seven days of hire by the director and program manager. |
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 physical plant inspection, the facility failed to ensure privacy so counseling sessions were not heard outside the counseling room in one of three buildings inspected during the survey.
The findings include:
A physical plant inspection was conducted on March 27, 2009 between 9:30 and 10:30 AM. Three separate buildings were inspected. Counseling sessions could be heard plainly and clearly from the counseling office on the second floor in building #335.
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Plan of Correction
The director of the program will order additional white noise machines to place outside counselor offices to ensure privacy for clients during counseling sessions. The clinical supervisor, program manager, and program director will ensure that all white noise machines are turned on during sessions, and an in service training will be conducted on the importance of privacy by the clinical supervisor. |
705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on a physical plant inspection, the facility failed to indicate an exit in two of three buildings reviewed.
The findings include:
A physical plant inspection was conducted about 9:30 to 10:30 AM on March 27, 2009. There was no sign indicating the second exit on either of the second floors in buildings # 335 and # 329.
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Plan of Correction
The director of the facility will contact the clinic's handyman to install two exit signs to indicate an exit in the two buildings that failed to have these signs. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the facility failed to notify clients in writing of a decision to terminate their treatment at the project in two of five client records.
The findings include:
Eighteen client records were reviewed on March 26-27, 2009. Written notification of intent to terminate the client's treatment was required in five client records. The facility did not document written notification of intent to terminate in client records # 3 and 5.
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Plan of Correction
The director and clinical supervisor will conduct a training to alert staff on when to notify the client, in writing, of a decision to voluntarily terminate the client's treatment. When a patient meets criteria for termination, the clinical supervisor will meet with the client to discuss the client's options for the program and other treatment alternatives. The program manager will monitor these meetings to ensure compliance. |
709.91(a)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on the review of administrative manuals and client records, the facility failed to restrict the reasons for involuntary termination to the reasons listed in the written plan.
The findings include:
Eighteen client records were reviewed on March 26-27, 2009. The policy and procedure manual and client handbook were both reviewed on March 25, 2009. Five records were reviewed for involuntary termination notification. Client records # 2 and 7 were discharged for financial reasons and client record # 4 was discharged for not attending all counseling sessions. Client record # 11 was given written notice of intent to discharge for not attending enough counseling hours, but was not actually discharged. These reasons for involuntary termination were not listed in the policy manual nor in the client handbook.
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Plan of Correction
The clinical supervisor will conduct a training with all staff members to review reasons for involuntary termination of a client. Additionally, all termination notices will be reviewed by the director and clinical supervisor to ensure they meet criteria for involuntary termination listed in the patient handbook and the policy manual. When a client is being involuntarily termination, the counselor of said client will contact the clinical supervisor and director to set up a meeting with the client. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document psychosocial evaluations in eight of nine client records.
The findings include:
Eighteen client records were reviewed on March 26-27, 2009. Nine records were reviewed for psychosocial evaluations. The psychosocial evaluation failed to document the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, client's attitude toward treatment and overall impressions based on the clinician's analysis of the collected historical information in client records #4, 10, 13, 14, 16, 17 and 18. These contained statements of the client and not the clinical impressions. In addition, # 11 contained conflicting details in different sections of the psychosocial; these discrepancies were not addressed.
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Plan of Correction
The clinical supervisor will conduct an in service training on documentation of client's problems/needs, support systems, coping mechanisms, negative factors, client's attitude toward treatment, and overall impressions based on the clinician's analysis of the collected historical information that needs to be indicated in each client's psychosocial. Additionally, the clinical supervisor will audit all new admission charts, specifically the psychosocial evaluations, to ensure compliance within 30 days from admission date. Corrections will be made accordingly to reflect that all information required is documented in the psychosocials. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document an individualized treatment plan in five of six client records.
The findings include:
Eighteen client records were reviewed on March 26-27, 2009. Six records were reviewed for comprehensive treatment plans. Client records # 1, 5, 10, 11 and 13 all had generalized goals that were similar if not identically written. Further, treatment plans # 1, 5, 10, 11, and 13 did not reflect the contents of the psychosocial.
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Plan of Correction
The clinical supervisor will conduct an in service training on documentation of individualized treatment plans that include contents of the psychosocial and goals specific to each individual client. The clinical supervisor will then address all deficiencies of documenation in the treatment plans before approving the plans.
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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 the review of client records, the facility failed to include support services on the treatment plans in five of six client records.
The findings include:
Eighteen client records were reviewed on March 26-27, 2009. Six client records were reviewed for treatment plans. The facility did not include proposed support services in client records # 1, 5, 9, 10 and 13.
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Plan of Correction
The clinical supervisor will conduct an in service training on types of support services that can be offered to clients and how to include these services in a client's treatment plan. The clinical supervisor will approve all treatment plans with support services included. The program manager will monitor to ensure compliance. |