INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the November 27 through November 29, 2012, licensure renewal inspection. The follow-up inspection was conducted on June 3 through 5, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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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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.
This was still out of compliance at the time of the follow up conducted on June 3 through 5, 2013.
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Plan of Correction
Program Director will provide a training to Medical Director, physician, and LPN staff on Verbal orders to ensure all Verbal Orders are signed within 24 hours on 6/19/13 and 6/20/13. Medical Director or Physician will not approve any Verbal Orders unless they have the ability to sign off within 24 hours.
Program Director will conduct audits on all orders on a quarterly basis to ensure compliance.
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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 one of two records reviewed.
The findings include:
Fourteen patient records were reviewed on June 4 and 5, 2013. Two patient records were reviewed for documentation of 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 client's progression of use in patient record # 11.
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Plan of Correction
A training will be Provided on 6/20/13 to clinical staff by the Clinical Supervisor on documenting the lengths and patterns related to the patients progression of drug and alcohol use. Clinical Supervisor to conduct individualized training during supervision as well with new staff. Clinical Supervisor to review all intake assessments to ensure compliance starting 6/21/13. Program Director to conduct quarterly audits to ensure compliance. |
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 the review of patient records, the facility failed to document a complete personal history in two of two records reviewed.
The findings include:
Fourteen patient records were reviewed on June 4 and 5, 2013. Two patient records were reviewed for a complete personal history. Patient records # 11 and 13 lacked detail in the personal histories by answering with one or two word answers and documenting a history that included only the past 30 days.
Patient # 11 was admitted on April 17, 2013. The facility failed to document family interrelationships history, a employment/vocational history, educational history, and sexual history.
Patient # 13 was admitted on January 28, 2013. The facility failed to document family interrelationships history, a employment/vocational history, educational history, and sexual history.
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Plan of Correction
A training will be Provided on 6/20/13 to clinical staff by the Clinical Supervisor on completing a complete personal history that includes detailed information. Clinical Supervisor to conduct individualized training during supervision and will conduct weekly chart audits starting 6/21/13 of assessments to ensure compliance. Program Director to conduct quarterly audits as well to ensure compliance.
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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 six of nine records reviewed.
The findings include:
Fourteen patient records were reviewed on June 4 and 5, 2013. Nine patient records were reviewed for documentation of initial and annual physical examinations that included documentation of the patient's general appearance. Patient records # 2, 3, 4, 5, 6 and 10 had identical general appearances. Every physical examination contained the following statement documented for the patient's general appearance, "alert, well oriented, normal speech pattern and gait." There were no additional comments by the physician that addressed the patient's general appearance.
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Plan of Correction
Program Director will provide a training to Medical Director, physician, CRNP, PA on 6/19/13 and 6/20/13. The training will focus on documenting general appearance that are unique to the patient. Program Director will conduct audits on a quarterly basis to ensure compliance. |
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 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 two of two records reviewed.
The findings include:
Fourteen patient records were reviewed on June 4 and 5, 2013. Two of the records were reviewed for the content of the psychosocial evaluation. Patient records # 11 and 13 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
The Clinical Supervisor will provide a training on 6/20/13 as well as individual training during supervision on documenting psychosocial evaluations that provide 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 clients current situation. Clinical Supervisor to conduct weekly audits starting 6/21/13 on all psychosocial evaluations to ensure compliance. Program Director to also complete quarterly audits to ensure compliance. |