INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15 - 16, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House New Castle 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 January 26, 2009.
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Plan of Correction
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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 facility training documentation, the facility failed to document training in the use of a fire extinguisher for one staff and failed to conduct the training in a timely fashion for three other staff.
The findings include:
Facility training documentation was review on December 15, 2008. There was no documentation of training in the use of fire extinguishers for the facility director, staff # 1. The training in the use of fire extinguishers for staff # 2, 3, and 4 was not conducted until five weeks beyond the start date.
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Plan of Correction
The Staff will be trained in fire safety with emphasis on the use of the fire extinguishers within the first week of initiating employment. The Director shall monitor, ensure and document this training in the appropriate binders (Training and Health & Safety). Will start immediately |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill logs, the facility failed to document the exit routes used during the fire drill on the fire drill logs in two of three months were fire drills were due..
The findings include:
The facility's fire drill logs were reviewed on December 15, 2008. The fire drill log entries for November 26, 2008 and December 3, 2008 failed to include documentation of the exit route used during the drill.
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Plan of Correction
Commencing on January 1, 2009, Fire Drills will be documented including the exit routes along with the other pertinent data.
The health and Safety Captain/Administrative Assistent will be responsible for documentation and diversion of exit routes.
Immediate compliance. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs and other written material pertaining to fire safety, the facility failed to document preparation of alternate exit routes to be used during the fire drills.
The findings include:
Fire drill logs and other fire and safety related material was reviewed on December 15, 2008. The facility did noto provide any documentation of the preparation of alternate exit routes to be used during fire drills.
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Plan of Correction
The Health and Safety Captain will begin the process of diversion (changing)of exit routes so the choices for persons leaving are subject to change and alternate routes are learned.
The same Captain and Director will be responsible for accurate documentation of the various exit routes. This shall commence January 1,2009. |
709.32(c)(5) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(5) Security of drugs.
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Observations
Based on a review of the facility policy and procedure manual on December 15, 2008, the facility failed to document a complete procedure for the security of all drugs.
The findings included:
The procedure listed on page 95 of the facility manual failed to state who, by job title, would carry out an investigation relating to the loss, theft and/or misuse of drugs and when, in relation to the discovery of the loss, theft and/or misuse of drugs, the investigation would be conducted.
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Plan of Correction
It will be brought to the attention of Home Office and the Board of Directors, the omission of who is responsible for the Investigation of lost,theft or misuse of of drugs and when this will be initiated in relation to the discovery of such loss. It will be recommended that the Director is the responsible party and the investigation will be initiated immediately upon knowledge of such loss.
It usually take 90 days to affect the entire process of a policy change. This will be completed by 5/29/09. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document complete psychosocial evaluations in 2 of 6 client records.
The findings included:
Six client records were reviewed on December 16, 2008. Client records #2 and 5 utilized psychosocial evaluations from another licensed facility that had been written and compiled in 2005. The current admission date for client record #2 was on 10/9/08 and for client record #5 on 10/10/08. In both client records there was a brief narrative regarding the clients' current status, but there was no current psychosocial evaluation.
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Plan of Correction
The Clinical Staff have been instructed that all new re-admits and transfers need an entirely new documentation of the psychosocial assessment if the document is a day older than six months. Within the six months, updating on the Psychosocial with initials and dates needs to be completed. Anything older is considered not relavent and time will be spent collecting new and current data.
The Clinical Supervisor will be responsible for monitoring as well as offering peridic in-services on expectations as well as regulations.
This will start January 1, 2009 |
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 document treatment plans within the timeframe stipulated by facility policy and procedure in 2 of 6 client records.
The findings include:
Six client records were reviewed on December 16, 2008. Client record # 4 documented an admission date of 10/17/08. The treatment plan documented in client record # 4 was dated 12/14/08. Client record # 5 documented an admission date of 10/10/08. The treatment plan in client record # 5 was dated 12/10/08. Page 166 of the facility policy and procedure manual states that treatment plans will be completed by the end of the fourth treatment session or within 30 days of the admission date, whichever comes first.
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Plan of Correction
There will be a review of these charts to illustrate the non-compliance to Discovery House Policy, with the Clinical Staff. There will be immediate and ongoing monitoring that these time lines are adhered to from January 1,2009 and continuing forward. An inservice will be held highlighting policies relating to Clinical areas. The Clinical Supervisor will be the responsible party. This is immediate and ongoing. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document support services on the treatment plans in six of six client records.
The findings include:
Six client records were reviewed on December 16, 2008. There was no documentation of proposed support services on the treatment plans in client records # 1 through #6.
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Plan of Correction
There will be an in-service to agree how best to ducument support services on the treatment plans.We will work on including such in the "General Note" box on the last page of each Treatment Plan.
It will be the responsibility of the Clinical Supervisor to mopnitor documentation of these services in the Treantment plans starting March 1, 2009 forward. The inservices will be immediate and ongoing. |