INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 27 through November 29, 2012, by staff from the Division of Drug and Alcohol 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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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 the review of personnel records, the facility failed to document fire extinguisher training upon staff employment in two of three personnel records reviewed.
The findings include:
Ten personnel records were reviewed on November 27, 2012. Three staff were hired within the last year and were reviewed to verify that staff had been instructed in the use of a fire extinguisher upon employment. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records #9.
Employee # 9 was hired on 11/1/2012. Fire extinguisher training was due upon hire. The facility documented fire extinguisher training on 11/13/2012.
This finding was confirmed by the clinical supervisor and facility director.
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Plan of Correction
Training was provided by Program Director to Health and Safety Captain on 705.28(c)(4). The program director or Health and safety captain will provide Fire extinguisher training as well as emergency training on the 1st day of hire. Program Director will monitor via employee chart reviews within 6 days of hire. This was completed as of 12/13/12. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 document all personnel were trained to perform assigned tasks during emergencies upon staff employment in two of three personnel records reviewed.
The findings include:
Ten personnel records were reviewed on November 27, 2012. Three employees were hired within the last year and were reviewed to verify staff had been trained to perform assigned tasks during emergencies upon employment. The facility failed to document the completion of training to perform assigned tasks during emergencies upon staff employment in personnel record # 9.
Employee # 9 was hired on November 1, 2012. Training to perform assigned tasks during emergencies was due upon hire. The facility documented emergency training on 11/13/2012.
This finding was confirmed by the clinical supervisor and facility director.
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Plan of Correction
A Training was provided by the Program Director to the Health and Safety Captain on Emergency procedures and training which needs to take place within times frames of regulations. The program director or Health and safety captain will provide Fire extinguisher training as well as emergency training which includes task identification on the 1st day of hire. Program Director will monitor via employee chart reviews within 6 days of hire. This was completed as of 12/13/12. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills were conducted during different times of the day.
The findings include:
The fire drill record was reviewed on November 27, 2012. Twelve months of fire drills were reviewed. The facility's hours of operation are from 5:00 a.m. until 12:00 p.m. The facility failed to document fire drills between the hours of 5:00 a.m.- 9:00 a.m. which is the facility's busiest time for patients to be at the clinic. All the drills were documented after 9:00 a.m.
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Plan of Correction
Training was provided by the Program Director to the Health and Safety Captain on Fire Drill procedures. The training focused on completing drills on different days of the week and during all hours of operation. Program Director will monitor by quarterly reviews during the Health and Safety meetings which are held quarterly. This was completed on 12/13/12. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of the facility's policy and procedures and patient records, the facility failed to ensure that verbal medication orders were put in writing and signed within 24 hours thereafter by the prescribing physician, as required by in two of two patient records.
The findings include:
Twenty patient records were reviewed on November 28-29, 2012. All verbal medication orders are required to be signed within 24 hours by the prescribing physician. Patient records # 4 and 8 contained documentation of a verbal medication order that was not signed by the prescribing physician within 24 hours.
Patient #4 was admitted on February 24, 2012 and discharged October 23, 2012. A verbal order dated September 21, 2012 was not signed by the prescribing physician until September 24, 2012.
Patient #8 was admitted on September 28, 2012 and discharged on October 5, 2012. A verbal order dated September 28, 2012 was not signed by the prescribing physician until October 4, 2012.
The above information was confirmed by staff and was not disputed.
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Plan of Correction
A training was provided to the Medical Director and Physician on Medication Control on 12/10/12 and 12/11/12 which focused on Verbal Orders and the regulation requiring the MD must sign off within 24 hours. Physician and Medical Director will ensure all orders are signed within 24 hours via electronic signature. Program Director will conduct quarterly reviews of all orders posted to ensure compliance. This was completed as of 12/11/12. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to verify the identity of the patient prior to the administration of an agent in one of two records reviewed.
The findings include:
Twenty patient records were reviewed on November 28-19, 2012. Two patient records were specifically reviewed for patient identity information. Patient record # 13 failed to have documentation that verified the patient's identity including patient name, address and date of birth.
This was confirmed by the facility director and was not disputed.
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Plan of Correction
A training was provided to Clinical and Medical staff on 12/13/12. The training focused on having a complete record prior to administration of medication. Clinical staff will provide copies of identifying information which include name, address, date of birth, and other identifying data. This will be reviewed by MD during his physical evaluation to ensure compliance. Program Director will complete chart reviews monthly to ensure compliance.
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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
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent prior to the administration of a narcotic agent for maintenance treatment.
The findings include:
Twenty patient records were reviewed on November 28-29, 2012. Thirteen patient records were reviewed for the completion of an informed, voluntary written consent prior to the administration of a narcotic agent. The facility failed to document the completion of an informed, voluntary, written consent prior to the administration of a narcotic agent in patient record # 10.
Patient # 10 was admitted into treatment on August 16, 2012 and discharged on August 24, 2012. The patient received their initial dose of methadone on August 16, 2012. There was no documentation of an informed, voluntary written consent prior to the administration of a narcotic agent in patient record # 10.
This finding was confirmed by the facility director and was not disputed.
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Plan of Correction
A training was provided to Clinical and Medical staff on 12/13/12. The training focused on having a complete record prior to administration of medication. Clinical staff will obtain an informed, voluntary, written consent during the initial evaluative appointment. This will be reviewed by MD during his physical evaluation to ensure it is completed before medication begins. Program Director will complete chart reviews monthly 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 the review of patient records, someone other than the narcotic treatment physician documented the patient's subsequent dose and schedule in two of three records reviewed.
The findings include:
Twenty patient records were reviewed on November 28-29, 2012. Three patients were administratively terminated. The records included termination notification letters. Two of the three termination notification letters documented dose change orders that were written by someone other than the narcotic treatment physician.
Patient # 9 received an administrative withdrawal notice on August 17, 2012. The notice documented the patient's dose would be decreased 5 mgs. per day until September 11, 2012. The letter was not signed by the narcotic treatment physician. The record was reviewed for documentation from the narcotic treatment physician initiating the dose change. The narcotic treatment physician wrote an order on August 21, 2012 stating the patient was to begin a 21 day administrative detox. There was no documentation in the record prior to the administrative notice being given to the patient that showed the narcotic treatment physician made the decision to decrease the patient's dose 5 mgs. per day.
Patient # 16 received an administrative withdrawal notice on August 13, 2012 at 8:58 a.m. The notice documented the patient was scheduled to started an administrative withdrawal on August 14, 2012. The letter stated the patient's dose would be decreased 6 mgs a day until August 21, 2012. The letter was not signed by the narcotic treatment physician. The record was reviewed for documentation from the narcotic treatment physician initiating the dose change. The narcotic treatment physician wrote an order at 9:46 a.m. This was documented after the letter was issued to the patient by their counselor.
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Plan of Correction
A training was provided to the Medical Director and Physician on 12/13/12 on administrative withdrawals which included termination notification and taper orders. The MD will determine all dose change orders and will document this via a general note as well as signing off on the administrative withdrawal notice. The Program Director will monitor via monthly chart audits of all administrative withdrawals. This took effect on 12/13/12. |
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
Based on the review of patient records, the facility failed to restrict the reasons for involuntary termination to the reasons allowed by regulation in one of three patient records.
The findings include:
Twenty patient records were reviewed November 28-29, 2012. Three patient records were reviewed for involuntary, or therapeutic discharge. One patient record contained documentation of the patient being discharged for reasons other than those listed by regulation.
Patient # 16 was admitted on July 20, 2012 and was administratively discharged on August 22, 2012. The patient received an administrative termination notification on August 13, 2012. The reason for termination listed on the termination notification letter was for non-compliance with treatment. However, there was a medical note documented on August 13, 2012 by the narcotic treatment physician that indicated the patient was being terminated for non compliance with treatment, continued drug use, financial reasons, and failure to comply with treatment plan objectives. The facility failed to limit the reasons for termination from treatment to those permitted by the regulation.
This finding was confirmed by the facility director.
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Plan of Correction
A training was provided to clinical supervisor, lead counselor, nurse manager, and medical director on 12/13/12. The training focused on the regulations for involuntary termination. The clinical supervisor and Program Director will review all administrative withdrawal requests to ensure compliance with regulation. MD will also review before signing off on all administrative withdrawal notifications and orders. This took effect on 12/13/12. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of patient records, the facility failed to document the lengths and patterns related to the patient's progression of drug and alcohol use in thirteen of thirteen records.
The findings were:
Twenty patient records were reviewed on November 28-29, 2012. Thirteen records were reviewed for documentation of a drug and alcohol history that included lengths and patterns related to the patient's progression of use. The facility failed to document the lengths and patterns related to the patient's progression of use in patient records # 2, 3, 4, 5, 8, 10, 12, 14, 15, 16, 17, 18, and 19.
This finding was discussed with the clinical supervisor and it was not disputed.
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Plan of Correction
A training will be provided on 12/19/12 by clinical supervisor and lead counselor on the intake procedures which includes obtaining and documenting drug or alcohol histories, documentation of lengths and patterns of use and progression of drug and alcohol use. Clinical Supervisor and Lead counselor will monitor via monthly chart reviews of all intakes for the prior month to ensure compliance. This will take effect on 12/20/12. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of the patient records, the facility failed to document a complete personal history in eleven of eleven records reviewed.
The findings include:
Twenty patient records were reviewed November 28-29, 2012. Eleven patient records were reviewed for a personal history that included prior treatment, family, legal, employment/vocation, educational, military, recreational and sexual history. Patient records # 2, 3, 4, 8, 10, 12, 14, 15, 16, 17, and 18 lacked detailed in the personal histories by answering with one or two word answers and documenting a history that included only the past 30 days.
Patient # 2 was admitted on 6/1/2012 and discharged on 7/3/2012. The facility failed to document family interrelationships, legal history, a detailed employment/vocational history, detailed educational history, and sexual history.
Patient # 3 was admitted on 3/13/2012 and discharged on 8/18/2012. The facility failed to document legal history, a detailed employment/vocational history, detailed educational history, and sexual history.
Patient # 4 was admitted on 2/24/2012 and discharged on 10/23/2012. The facility failed to document legal history, a detailed employment/vocational history, detailed educational history, and sexual history.
Patient # 8 was admitted on 9/28/2012 and discharged on 10/5/2012. The facility failed to document legal history, a detailed employment/vocational history, detailed educational history, and sexual history.
Patient # 10 was admitted on 8/16/2012 and discharged on 8/24/2012. The facility failed to document legal history, a detailed employment/vocational history, detailed educational history, and sexual history.
Patient # 12 was admitted on 7/16/2012. The facility failed to document prior treatment history, legal history, a detailed employment/vocational history, detailed educational history, military, and sexual history.
Patient # 14 was admitted on 8/9/2012. The facility failed to document family interrelationships, legal history, a detailed employment/vocational history, detailed educational history, and sexual history.
Patient # 15 was admitted on 8/29/2012. The facility failed to document legal history, a detailed employment/vocational history, detailed educational history, and sexual history.
Patient # 16 was admitted on 7/20/2012 and discharged on 8/22/2012. The facility failed to document legal history, a detailed employment/vocational history, detailed educational history, and sexual history.
Patient # 17 was admitted on 10/12/2012. The facility failed to document a detailed employment/vocational history, detailed educational history, military history, and sexual history.
Patient # 18 was admitted on 10/9/2012. The facility failed to document a detailed employment/vocational history, detailed educational history, and sexual history.
The findings were reviewed with the Clinical Supervisors on November 29, 2012 and were not disputed.
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Plan of Correction
A training will be provided on 12/19/12 by the clinical supervisor and lead counselor on intake procedures which includes obtaining and documenting family interrelationships, legal history, employment/vocational history, educational history, and sexual history. Clinical Supervisor and Lead counselor will be responsible and will monitor via monthly chart reviews of all intakes for the prior month. This will take effect on 12/20/12. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on the review of patient records, the facility failed to document a physical examination that included a general appearance that was unique to the patient in fourteen of fourteen records reviewed.
The findings include:
Twenty patient records were reviewed on November 28-29, 2012. Fourteen patient records were reviewed for initial physical examinations that included documentation of the patient's general appearance. Patient records # 2, 3, 4, 8,10, 12, 13, 14, 15, 16, 17, 18, 19 and 20 had identical general appearances. Every physical examination contained the following statement documented for the patient's general appearance, "pleasant, alert and well oriented." There were no additional comments by the physician that addressed the patient's general appearance.
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Plan of Correction
A training was provided by Program Director on 12/13/12 to Medical Director and Physician on physical evaluations which included documentation of general appearances. MD and Physician will document a individualized general appearance in the physical history. Program Director will monitor via monthly chart reviews of all new admissions. This took effect on 12/13/12.
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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 patient records, the facility failed to document psychosocial evaluations that provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in seven of eleven records reviewed.
The findings included:
On November 28-29, 2012, twenty patient records were reviewed. Eleven of the records were reviewed for the content of the psychosocial evaluation. Patient records # 2, 3, 8, 10,16,17, and 18 failed to include a psychosocial evaluation that included a composite picture of the client's problems and needs to be addressed in treatment, the client's assets and strengths, coping mechanisms, support systems, the negative factors that might inhibit treatment, and the counselor's impressions regarding the patient. The documentation included a repeat of the patient reported information and did not include an evaluation by the clinician for all required components.
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Plan of Correction
A training will be provided on 12/19/12 by clinical supervisor and lead counselor to all clinical staff on obtaining and documenting a psychosocial evaluation that includes a composite picture of Strengths, needs, assets, and problems, as well as coping mechanisms, support systems, negative factors and counselor impressions regarding the patient. Individualized trainings will also be utilized for staff needing additional training. Clinical Supervisor and lead counselor to review all psychosocial evaluations before being posted as completed. Clinical Supervisor and Director will be responsible. This will take place on 12/19/12. |
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 patient, the facility failed to provide written documentation of the proposed type of support services on the individual treatment and rehabilitation plans, in four of nine patient records reviewed.
The findings include:
Twenty patient records were reviewed on November 28-29, 2012. Nine records were reviewed for individual treatment and rehabilitation plans that documented proposed type of support services. The facility did not document proposed type of support services in on the individual treatment and rehabilitation plan in patient records # 3, 12, 17 and 18.
Patient # 3 was admitted on March 13, 2012. The individual treatment and rehabilitation plan was completed May 24, 2012. There were no support services documented on the treatment plan.
Patient # 12 was admitted on July 16, 2012. The individual treatment and rehabilitation plan was completed August 15, 2012. There were no support services documented on the treatment plan.
Patient # 17 was admitted on October 12, 2012. The individual treatment and rehabilitation plan was completed November 8, 2012. There were no support services documented on the treatment plan.
Patient # 18 was admitted on October 4, 2012. The individual treatment and rehabilitation plan was completed November 13, 2012. There were no support services documented on the treatment plan.
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Plan of Correction
A training will be provided on 12/19/12 on writing individualized treatment plans. This training will also review standards associated with documentation of proposed support services. Individualized trainings will also be utilized for staff needing additional training. Clinical Supervisor and lead counselor to review Treatment plans before being posted as completed. Clinical Supervisor and Director will be responsible. This will take place on 12/19/12. |