INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 29, 2008 through October 31, 2008 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 and a plan of correction is due on December 1, 2008.
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Plan of Correction
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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 records and staff interview on October 29, 2008 through October 31, 2008, the facility failed to document the exit route used on fire drill records.
The findings include:
The exit route used was missing in seven of ten months of fire drill records reviewed. Fire drill records were reviewed for the months of January 2008 through October 2008. The exit route used was not documented for January 2008, February 2008, April 2008, May 2008, June 2008, July 2008, or September 2008.
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Plan of Correction
A training will be provided to the Health And Safety Team by the Program Director on proper documentation of fire drills to include documenting exit routes used. The Health and Safety Chairperson will document exit routes used during the fire drills on the fire drill test document. Program Director will sign off on all fire drills before placing them in the Health and Safety Binder to ensure compliance. This will take effect within 30 days. |
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 sixteen client records on October 29, 2008 through October 31, 2008, the facility failed to document complete psychosocial evaluations in fourteen of sixteen client records where required.
Findings:
Psychosocial evaluations were missing an evaluation of client assets/strengths in client records #1, 2, 4, 8, 13 and 14. The client's assets/strengths listed were client reported and not evaluative. Psychosocial evaluations were missing the client's potential or available support systems in client records #2, 10 and 13. The client's potential or available support systems were client reported in client record #12. Psychosocial evaluations were missing the client's preferred coping mechanisms in client records #2, 4, 6, 7, 8, 9, 10, 11, 12, 13, 15 and 16. Psychosocial evaluations were missing negative factors that may affect treatment in client records #1, 2, 6, 8, 9, 12 and 13.
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Plan of Correction
Program Director will provide a training to entire Psychosocial staff on writing psychosocial evaluations which will focus on including the clients assets/strengths in a evaluative format, potential or available support systems, preferred coping mechanisms, and negative factors that may affect treatment. This training will take place within 30 days. Clinical Supervisor, Lead Counselor, and Program Director will review psychosocial evaluations during individual supervision and monthly chart audits to ensure compliance. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of sixteen client records and facility procedure on October 29, 2008 through October 31, 2008, the facility failed to complete preliminary treatment plans within the facility required timeframe, in ten of sixteen client records where required.
The findings include:
Facility policy states the preliminary treatment plan will be developed within three days of the date of admission. Preliminary treatment plans were developed more than three days after admission in client records #4, 5, 6, 8, 9, 10, 11, 12, 14 and 15.
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Plan of Correction
A memo will be provided by the Program Director to all counseling staff that requires a signature of understanding that all preliminary treatment plans will be completed within 3 days of the admission date. This will be completed within 30 days. Program Supervisor will review all initial treatment plans before signing off as complete to ensure time frames are followed. Program Director will also review time frames on a monthly basis via chart audits to ensure compliance. |
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 sixteen client records on October 29, 2008 through October 31, 2008, the facility failed to complete individual treatment plans in a timely manner, according to facility policy, in seven of fifteen client records where required.
The findings include:
Facility policy states the individual treatment plan will be developed within thirty days of the date of admission. The individual treatment plan was developed more than 30 from the date of admission in client records #1, 3, 8, 9, 10, 11, 12 and 14.
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Plan of Correction
A memo will be provided by the program Director to all counseling staff that requires a signature of understanding that all treatment plans will be completed within 30 days of the admission date. This will be completed within 30 days. Program Supervisor will review all treatment plans before signing off as complete to ensure time frames are followed. Program Director will also review time frames on a monthly basis to ensure compliance. |
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 sixteen client records on October 29, 2008 through October 31, 2008, the facility failed to document support services on the individual treatment plan in twelve of fifteen client records where required.
The findings include:
The individual treatment plan was missing support services in client records #1, 3, 4, 5, 6, 7, 8, 9, 10, 12, 15 and 16.
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Plan of Correction
A training will be provided by the Clinical Supervisor to all counseling staff on documentation of support services in the treatment plan. This will be completed within 60 days. Clinical Supervisor and Lead Counselor will view all treatment plans before accepting them as complete to ensure support services are documented in the treatment plan. Program Director will conduct chart reviews on a quarterly basis to ensure compliance. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of sixteen client records on October 29, 2008 through October 31, 2008, the facility failed to document complete aftercare plans in thirteen of sixteen client records where required.
The findings include:
Facility policy states the aftercare plan will begin to be developed at admission. An aftercare plan was missing in client records #3, 13, 14, 15 and 16. Aftercare plans were missing measurable goals in client records #2, 5, 6, 7, 8, 9, 10 and 11. Aftercare plans did not include specific time frames for completion in client records #6, 7, 10 and 11. The time frames listed included "ongoing" and "indefinitely."
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Plan of Correction
The Program Director will provide a training to clinical staff on after care planning. The training will focus on review of policy which defines when after care plans are to be completed with patient and content of after care plans which will include measurable goals and specific time frames for completion. This will take place in 60 days. Clinical Supervisor and Program Director will complete chart audits to ensure compliance on a monthly basis. |
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 a review of sixteen client records on October 29, 2008 through October 31, 2008, the facility failed to document a complete discharge summary in three of five client records where required.
Findings:
Sixteen client records where reviewed from October 29 through 31, 2008. The discharge summary was missing the reason for treatment in client records #12, 13 and 14. Facility policy and state regulation state the discharge summary will be completed within one week after discharge. The discharge summary was three weeks late in client record #13.
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Plan of Correction
The Program Director will provide a training to clinical staff on discharge planning which will focus on documenting the reason for treatment and review of policy showing times frames when this is to be completed. This will be completed within 60 days. Clinical Supervisor and Program Director will review Discharge Summaries during monthly chart audits to ensure compliance. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that the project director complete at least 12 clock hours of training annually.
The findings include:
Eight personnel records were reviewed on October 29, 2008 through October 31, 2008. The project director had zero training hours documented for the 2007 annual training year. There was no documentation of training in one of one personnel record where required.
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Plan of Correction
The Project Directors training hours will be on site for review for future audits. This will take place within the next 30 days. Program Director will monitor quarterly to ensure training hours are updated in the associates file. |