INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on December 11-13, 2018 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, 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:
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Plan of Correction
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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
The facility failed to document a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served and that every effort will be made to hire staff persons representative of that population.
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Plan of Correction
The Regional Director will work with the Corporate Human Resource Department to develop a policy that is in compliance with the State of PA regulation regarding recruitment and hiring. |
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 must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to document a confidentiality policy and procedure which complies with 4 Pa Code 255.5.
The revised policies and procedures were reviewed. In the "Confidentiality of Patient Records" section, it states that information about suspected violations of elder abuse must be reported; however, suspected elder abuse is not an exception to Pa Code 255.5. In addition, the policy states that Federal laws and regulations do not protect information about a crime committed by a patient or any threat to commit such a crime; however, the state regulations do protect this information. Only if the crime is committed on program premises or against program personnel would it allow the information to be released without a valid consent.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Services Department will revise the policy on the Confidentiality of Patient Records to bring the policy into conformance with the State of PA Regulations. The Clinical Services Department will notify the of the policy revision. The Project Management will review the Policy revisions with staff in the February 2019 all staff meeting. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document written policies and procedures regarding all of the client rights.
The revisions to the policy and procedures manual and client handbook were reviewed. Neither the policy manual nor the client handbook documented 709.30 -
(1) A client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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(3) The project, facility or clinical director may temporarily remove portions of the records prior to inspection by the client if the director determines that the information may be detrimental of presented to the client.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the 2017 licensing inspection.
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Plan of Correction
The Clinical Services Department will revise the Client Rights Policy and Patient Handbook to ensure they are in conformance with the State of PA Regulations. The Clinical Services Department will notify Project Management of the approved revisions. The Project Management will review the revisions with all staff at the February 2019 staff meeting. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
The facility failed to provide at least 1 hour of physician services per week for every ten patients.
During the week of July 29 - August 4, 2018, the patient census was 385. The facility was required to provide at least 38.5 physician hours. There were 13 physician hours documented.
During the week of August 19 - 26, 2018, the patient census was 389. The facility was required to provide at least 38.9 physician hours. There were 13 physician hours documented.
During the week of September 16 - 23, 2018, the patient census was 391. The facility was required to provide at least 39.1 physician hours. There were 13 physician hours documented.
During the week of October 14 - 21, 2018, the patient census was 397. The facility was required to provide at least 39.7 physician hours. There were 35.75 physician hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic will ensure there is at least 1 hour of physician services per week for every ten patients.
The Facility Director will also work with the Regional Director to develop a plan by February 9, 2019 for back-up medical coverage in the event of a planned or unplanned absence by the Medical Team.
The Facility Director will utilize the back-up coverage plan in the event of a planned or unplanned absence by a Medical Team member. |
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
The facility failed to document an informed, voluntary, written consent before an agent (methadone) was administered in patient record #8.
Patient #8 was admitted to treatment on August 27, 2018 and the patient's first dose of methadone was on the same day. There was no documentation of an informed consent to treatment in patient record #8.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Admission Team developed a binder containing all Patient Admission Forms including the Informed, Voluntary, Written Consent to Treatment. The Admission Team is designated by the Director to review each Admission Form with each new admission and then is responsible to ensure each form is signed in the electronic medical record before an agent(methadone)is administered. The binder is in effect at the time of this Plan of Correction.
The Senior Counselor is designated by the Director to audit all new patients Admission Forms to ensure all Admission Forms are signed in electronic medical record. This new audit process is active at this time of this Plan of Correction.
The Director is responsible for ensuring the forms are reviewed with the patient, signed in the electronic medical record before an agent (methadone) is administered. The Director is also responsible for ensuring the Senior Counselor audits the charts for compliance with this Plan of Correction. This process is in place at the time of this Plan of Correction. |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
The facility failed to develop policies and procedures which limited the reasons for involuntary termination to those conditions permitted by regulation. In addition, the policies and procedures should include providing a detoxification of at least 7 days, except when a patient commits or threatens to commit acts of physical violence.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Services Department will revise the Termination Policy to bring the Policy and Procedure in full conformance with the State of PA Regulations. The Clinical Services Department will inform the Facility Director of the Policy changes.
The Facility Director will review the revised policy and procedure with staff at the February 2019 staff meeting. |