INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 3-5, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health-Ha,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 December 18, 2009.
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Plan of Correction
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on the physical plant tour on 11/4/09 at 4 PM, the facility failed to ensure that each bathroom is ventilated by an exhaust fan or window.
The findings included:
Bathrooms were inspected during the physical plant tour . Five bathrooms in all were inspected. Each was required to have a window or working exhaust fan for ventilation. None of the five bathrooms had a window or a working exhaust fan . The facility director was aware of this issue and there is a plan in place to have fans installed as the next phase of the renovations for the new facility but they were not compliant at the time of inspection.
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Plan of Correction
We have contacted the HVAC person and he has started the repair to the fans, repairs will be completed by December 31, 2009. The Program Director will follow till completion |
705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
Based on a review of the emergency preparedness plan and an interview with the facility director, the facility failed to document a written procedure for staff and clients to follow in case of an emergency; which shall include the evacuation and transfer of clients and staff to a safe location.
The findings include:
The emergency preparedness plan was reviewed on November 5, 2009. The emergency preparedness plan did not include a safe location inside of the building for clients and staff; in the event an emergency/catastrophe occurs outside of the facility. The facility director reports the emergency preparedness plan only includes a safe location outside of the building; for clients and staff to evacuate to in case of a fire or other internal emergency.
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Plan of Correction
During the audit Program Director was asked to submit material to the state to address this regulation and sent the wrong information. The information needed is in our Health and Safety Binder under our Emergency Action Plans. This plan lays out a complete guideline of evacuation from the building by associates and patients and the exits to use leading to a safe meeting point in case of emergency. The Health and Safety Binder is kept in a central location for access to all associates. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on the physical plant tour of 11/4-5/2009, the facility failed to ensure that fire extinguishers were each inspected and approved annually by the local fire department or fire extinguisher company.
The findings included:
At the time of the physical plant inspection there five fire extinguishers on the premises. Three of the fire extinguishers had inspection tags documenting the last date of inspection as April 2009. Two of the fire extinguishers had inspection tags on them which documented that they were last inspected in September of 2008. The requirement for an annual inspection /approval was not met for two of five fire extinguishers on site.
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Plan of Correction
The two fire extinguishers have been tagged by White Fire Extinguisher Co and are in compliance till Nov 2010. The Program Director signed off on the work order. |
709.22(d)(3) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(3) Describing the project's organizational structure.
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Observations
Based on the review of the agency policy and procedures presented to Division staff on November 4, 2009 and reviewed on November 5, 2009 , the facility failed to document an organizational chart which accurately reflected the organizational structure at the local clinic level.
The findings included:
During the onsite review of the agency organizational chart, the facility did not provide a copy of the organizational structure at the clinic level. The chart failed to document the structure as it pertained to the counseling staff, nurses and support staff at the clinic level.
The facility director confirmed that she did not have documentation of an organizational chart which included counselors, nurses and other support staff.
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Plan of Correction
The organization structure has been changed to include all clinic level associates. A copy has been posted in the lobby and in the appendicies. Program Director will be responsible to update in the event of any changes. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of administrative policies and procedures, the 2008 annual report and an interview with the facility director, the governing body failed to document a financial statement of income and expenses, as required in the annual report.
The findings include:
Administrative policies and procedures and the 2008 annual report were reviewed on November 5, 2009. The annual report for the year ending December 2008 was included in the Discovery House, Pennsylvania Appendices manual. There was no documentation of a financial statement of income and expenses in the 2008 annual report. The facility director was only able to provide a copy of a policy regarding annual reports; but could not provide documentation of a financial statement of income and expenses in the 2008 annual report.
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Plan of Correction
Additional information for the Annual Report has been added included are the Clinic Vitals signs which includes our census, private AR, 3rd Party AR, bad debt, Sales, gross payroll. We have also included our clinic expenses in a breakdown of Payroll, Payroll Taxes, Facility Costs, Office Cost, Payroll benefits, Lab fees, Professional Services, Bad Debt, Medical Supplies, Depreciation & Amortization. Also included For 12 Months ending December 31, 2008 Revenue Total Revenue figure and Total Expenses. This will be kept current by the Program Director. |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on a review of administrative policies and procedures, the 2009 - 2012 Strategic Plan and an interview with the facility director, the facility failed to provide documentation of a performance report summarizing the progress towards meeting annual goals and objectives.
The findings include:
Administrative policies and procedures and the 2009 - 2012 Strategic Plan were reviewed on November 5, 2009. The facility failed to provide documentation of a performance report summarizing the progress towards meeting annual goals and objectives. The facility director confirmed she did not have a performance report summarizing the progress of annual goals and objectives.
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Plan of Correction
Annual review summarizing the progress toward meeting annual goal and objectives will be completed and posted on the intranet for access. This will be followed up by the Program Director |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of administrative policies and procedures and an interview with the facility director, the facility failed to provide documentation of complete written procedures for the management of treatment/rehabilitation services for clients.
The findings include:
Administrative policies and procedures were reviewed on November 5, 2009. The written plan did not include time frames or who, by job title, would be responsible for the development, approval, monitoring and evaluation of client services in the following policy/procedure statements:
The medical history was addressed as part of the intake process but failed to stipulate the need to collect the family medical history.
There was no time frame for the completion of the individual treatment and rehabilitation plans. There was no reference to the required content of the treatment plan, such as, short and long term goals, type and frequency of treatment and the proposed type of support services.
There was no time frame provided for the completion of treatment and rehabilitation plan updates.
Records of services were not addressed in the written procedures for the management of treatment and rehabilitation services.
Documentation of referral contacts and client correspondence was not addressed in the written procedures.
Case consultations did not address who, by job title, was responsible for documenting the case consults, what the required content of the case consultation was and when it would be conducted. .
The facility director confirmed that she did not have any additional information to provide regarding the written procedures for treatment/rehabilitation services for clients.
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Plan of Correction
We have developed a Written Plan to include time frames, who by job title will be responsible for the development, approval, monitoring, and evaluation of client services, The Program Director met with the other Pennsylvania Program Directors to come up with the list to include all the requirements by the State. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of facility materials during the onsite licensing inspection , the facility failed to document an audit for the year ended 12/31/2008.
The findings included:
Division staff reviewed the documentation presented when the annual audit was requested. The documentation presented by the facility director consisted of a financial statement for the year ended 12/31/08. The letter from the accountant stated"...we have not audited or reviewed the accompanying financial statements and do not express an opinion or any other form of assurance on them." There is a statement of income and expenses and balances. The documentation presented failed to meet the requirement for the annual financial audit.
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Plan of Correction
Discovery House will conduct an audit for FY 2010. We will submit a 2009 compellation review and an engagement letter for 2010. The Program Director will be responisible. I |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the policy and procedure manuals submitted by the facility corporate office prior to the inspection and on a review of the policy and procedure for the confidentiality of client records on site, the facility failed to provide for a complete and accurate policy and procedure relative to the confidentiality of client identity and records.
The findings include:
The policy and procedure manual was reviewed prior to the inspection and again during the licensing inspection conducted from November 3, 2009 to November 5, 2009.
Page 47 of the manual refers to the electronic record keeping system and the 'Eligibility Verification System' which contacts the third party payer to confirm eligibility. The written policy does not indicate that prior to such an attempt to contact the third party payer, the client's written consent must be obtained. to state law at 71 P. S. Subsection 1690.108(b).
Page 172 of the manual states that the facility provides the coordination and ongoing communication between service providers (letters of agreement/Qualified Service Agreement Plans-QSAPs). Treatment programs do not provide services to each other. Qualified Service Organization Agreements cannot be executed between treatment providers. The client/patient must sign a written consent to release information before such information can be released.
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Plan of Correction
Patient will sign appropriate releases before accessinig EVS information or providing information to any outside agency. This will be addressed in our Associates Meeting. The Program Director and Clinical Supervisor will follow up to insure compliance. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of client records and the client handbook, signed off by each client, the facility failed to notify clients of the right to submit rebuttal data or memoranda to his own records.
The findings included:
Twenty seven client records were reviewed during the onsite inspection. No documentation was available to demonstrate in the record that each client was informed of his/her right to submit rebuttal information to their treatment record.
The following client records failed to document that clients were informed of their right to submit rebuttal information to their treatment records: # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 and 27. The client right was not posted anywhere that would have been visible to the client.
Staff were interviewed on November 4 and 5, 2009 regarding the clients not being informed of this right and were given the opportunity to present additional documentation to demonstrate that clients received appropriate notification. Administrative staff including the facility director, clinical supervisor, and lead counselor were present throughout the survey and could not demonstrate that clients were informed of this right.
The regional director was present at the exit summary and an administrative officer from the home office in Rhode Island was involved in the exit summary via teleconference.
The officer from Rhode Island referred to a page in the client handbook which was to contain the information required. The material referenced by the officer from Rhode Island was not in the handbook located at the facility.
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Plan of Correction
The handbook has been revised to state under Client Rights they have the right to rebuttal information to their record. All the incorrect handbooks have been destroyed and we have the new handbooks on site. The Program Director was responsible for the correction and destruction of incorrect handbooks. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on the review of client records during the onsite licensing inspection and an interview with the Facility Director on 11/5/09, the facility failed to document that physical examinations were completed before each client received their initial dose of methadone.
The findings included:
Twenty six client records were reviewed . In twenty four client records, the physician signature on the physical examination post dated the initial date of dosing .
The facility director was interviewed on November 4 and 5, 2009 and she stated that the physician always completes the physical prior to the initial dosing on a hard copy of the physical examination form and signs and dates this form prior to dosing. She related that after this form is entered onto the electronic record, the hard copy of the form is discarded. The facility director did not offer to produce any examples of hard copy physical examination forms during the inspection of November 3 through 5, 2009.
Specifics are listed below:
Record #/admit dateDate of physician signature on the examDate of initial dosing
on the physical examination form
1, 6/22/096/24/096/22/09
2. 8/4/098/5/098/4/09
4. 5/29/096/3/095/29/09
6. 7/13/097/14/097/13/09
7. 1/27/091/28/091/27/09
8. 8/25/098/27/098/25/09
9. 9/1/099/2/099/1/09
11.4/23/094/28/094/23/09
12.10/7/0910/8/0910/7/09
13.6/12/096/16/096/12/09
14.6/11/096/16/096/12/09
15.6/2/096/3/096/2/09
16.6/4/096/15/096/4/09
17.6/24/096/25/096/24/09
18.6/25/096/26/096/25/09
19.6/17/096/19/096/17/09
20.6/16/096/19/096/16/09
21.9/3/099/4/099/3/09
22.9/17/099/18/099/17/09
23.9/30/099/18/099/17/09
24.9/30/0910/2/099/30/09
25.9/17/099/18/099/17/09
26.9/11/099/15/099/11/09
27.9/4/099/8/099/4/09
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Plan of Correction
The Medical Director or designee who performed the initial physical exam will consult and discuss the initial physical exam to determine the initial methadone dose. The physical exam will be documented in the patient chart before being admitted to the program. This will be monitored by the Program Director and Clinical Supervisor through chart audits and periodic examine of charts |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on the review of client records on November 3, 4 and 5 , 2009, the facility failed to document reasons for treatment and a complete record of the types of services offered to the client on discharge summaries in 5 of 7 client records.
The findings included:
Seven closed client records were reviewed during the inspection. Four of seven client records failed to include documentation of the reasons for treatment ( 1, 3, 4 and 7). Client records # 1, 2, 3 and 7 failed to include documentation of the services provided.
Client record # 1- admitted 6/22/09 discharged 9/22/09. There was no documentation of the reasons for treatment or the services provided, specifically group and individual counseling, on the discharge summary.
Client record # 2- admitted 7/31/09 discharged 9/4/09. There was no documentation of the services provided, specifically group and individual counseling, on the discharge summary.
Client record # 3- admitted 6/25/09 discharged 8/10/09. There was no documentation of the reasons for treatment or the services provided, specifically group and individual counseling, on the discharge summary.
Client record # 4 - admitted 5/29/09 discharged 9/29/09. There was no documentation of the reasons for treatment on the discharge summary.
Client record # 7 - admitted 1/27/09 discharged 8/20/09. There was no documentation of the reasons for treatment or the services provided, specifically group and individual counseling, on the discharge summary.
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Plan of Correction
The Clinical Supervisor will hold an inservice on the Discharge documention which will show patients attended individual and group counseling and reason for treatment other than opiate addiction. This will be monitored by the Clinical Supervisor through chart audits and reinforce periodiacally in future meetings. |
709.94(d) LICENSURE Project management services
709.94. Project management services.
(d) The project shall develop a written client aftercare policy.
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Observations
Based on a review of facility policies and procedures and an interview with the facility director, the facility failed to document a complete written client aftercare policy.
The findings include:
The facility's aftercare policy was reviewed on November 5, 2009. The facility failed to document an aftercare policy which identifies who, by job title, develops the aftercare plan with the client, when the aftercare plan is to be completed and what contents the aftercare plan will include.
The facility director confirmed she did not have any additional information to provide regarding the aftercare policy.
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Plan of Correction
The aftercare policy will include a grid of associates responsible by job title and time frames for completion. This will be followed up by the Program Director. Once this policy is completed this will be reviewed with all clinical associates. |