INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 19-21, 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 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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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.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the 2017 licensure inspection.
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Plan of Correction
The Regional Director will work with the Corporate HR department to develop a policy that is in compliance with the regulation regarding recruitment and hiring. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
The facility failed to ensure staff caseloads remained at or under 35:1.
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on November 19, 2018. Based on the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week and the total number of clients assigned to the following employees on November 19, 2018 employees # 3 and 6 exceeded the allowable maximum 35:1 caseload.
Counselor # 3 had an FTE caseload of 41:1
Counselor # 6 had an FTE caseload of 38:1
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Supervisor will redistribute clients to ensure each caseload is a 35:1 ratio for active patients to counselor.
Clinic Director will monitor and maintain a qualified pool of potential counselors to assure facility maintains a 35:1 ratio.
The Clinic Director will continue to work with Human Resources Business Partner in the recruitment and hiring of appropriate staff for the project and to ensure that the FTE counselor caseload for counseling in an outpatient program does not exceed 35:1 active patients.
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
The facility failed to maintain all structures and grounds free from danger to health and safety and store all trash in covered containers.
On November 19, 2018, an outlet was observed to be coming out of the wall with exposed wires in a counseling office.
In addition, the dumpster lids were observed to not fully close.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director will contact the local waste removal agency to replace the dumpster with another dumpster that closes completely. The Clinic Director will monitor and check the dumpster quarterly when completing quarterly exterior building audits. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to have hot water under pressure and ventilate bathrooms by exhaust fans or window.
A physical plant inspection was conducted on November 19, 2018. The men's staff restroom was observed to have an inoperable exhaust fan and no window. In addition, there was no hot water in the building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director will contact a plumber and electrician contractor to repair the water heater for hot water access within the bathrooms. The Clinic Director will be checking the water during quarterly building inspections.
The Clinic Director will contact an electrician to replace the exhaust fan in the men's bathroom for proper ventilation. The Clinic Director will monitor the bathroom exhaust fans while performing quarterly building inspections to ensure all exhaust fans are working properly.
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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
The facility failed to instruct staff on the use of fire extinguishers upon staff employment.
Staff #3 was hired as a counselor on February 5, 2018 and was not instructed on the use of fire extinguishers until October 25, 2018.
Staff #4 was hired as a counselor on April 30, 2018 and was not instructed on the use of fire extinguishers until October 25, 2018.
Staff #5 was hired as a counselor on 1/24/18 and was not instructed on the use of fire extinguishers until October 25, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire extinguisher training checklist has been added for new staff employees. An employee signature acknowledgement 16.1 Health & Safety form has been established and an employment checklist will be completed on the first day of employment by the Clinic Director and the Health and Safety Captain. The Clinic Director will review the checklist for compliancy quarterly. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct unannounced fire drills at least once a month.
The fire drill logs from January 2018 through October 2018 were reviewed on November 19, 2018. There were no fire drills conducted for the months of May and June 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Drills will conducted every month in addition to specific emergency drills such as Medical Emergency, Natural Disaster, Utility Failure, Workplace Threat & Violence/Active Shooter, and Bomb Threats.
All fire drill logs will be filed in the health and safety binder by the Health and Safety Captain after reviewed and signed by the Clinic Director.
In addition, the Clinic Director will review the health and safety binder monthly for completeness and compliancy.
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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
Clinical Services Department will revise the policy on Confidentiality of Patient records to bring the policy into conformance with the regulations. Project Management will review Policy revisions with staff in the January 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.
and
(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
Clinical Services Department will revise the Client Rights policy and procedure and the Patient Handbook to bring the Policy and Patient Handbook into conformance with the regulations. Project management will review policy and procedure revisions with all staff at the January 2019 staff meeting. |
709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
The facility failed to fully document medication errors in the client record.
Client #9 was given a prescription for Suboxone on September 14, 2018; however, she was taking Subutex as she was breastfeeding. Client #9 called the facility to report the error. There was no further documentation in client record #9.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Nurse Manager will review prescriptions with Medical Doctor before the prescriptions are distributed to the patient. The nurse manager will also develop a medication error report checklist to be reviewed at the end of each day patients are required for doctor's visits and properly stored in clients chart. The Clinic Director will review the checklist quarterly for accuracy. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to file a written unusual incident report with the Department within 3 business days following an event at the facility requiring the presence of police, fire or ambulance personnel.
The unusual incident reports were reviewed on November 19, 2018. Ambulance personnel was present at the facilty on April 27, 2018 and police were present at the facility on October 9, 2018 and October 27, 2018. There was no documentation that unusual incident reports were filed with the Department within 3 business days for the aforementioned events.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director will file the PA Dept. of Drug & Alcohol unusual incident reporting form narcotic treatment program form with the Department within 3 business days following an event at the facility that requires the presence of police, fire or ambulance personnel or other occurrence which closes the facility for more than one day including if the project requires the presence of police, fire, or ambulance personnel on site. |
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 August 26 - September 1, 2018, the patient census was 479. The facility was required to provide at least 47.9 physician hours. There were 42 physician hours documented.
During the week of November 4-10, 2018, the patient census was 490. The facility was required to provide at least 49 physician hours. There were 32 physician hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director physician services shall provide at least 1 hour per week onsite for every ten patients. A scheduled calendar of physicians will be submitted to the medical staff monthly to ensure there is adequate coverage. The Clinic Director will monitor the monthly calendar to ensure there is adequate coverage.
. "Ongoing compliance will be monitored during quality record reviews. Continued non-compliance will be addressed via the EIP process."
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715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to document that female patients had been fully informed of the possible risk to an unborn child from continued use of illicit drugs and from use of, or withdrawal from, a narcotic drug administered in treatment.
Client #12 , a female patient, was admitted into buprenorphine treatment on January 18, 2018. There was no documentation of risk information being provided to client #1.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Patient Pregnant Acknowledgement of Risks Form has been added to the intake process checklist. Counselors will be responsible for assuring new pregnant female patients are educated on the risks of MAT and pregnancy. New patients will review and acknowledge the information with their signature on the form. Clinical Supervisor will review new admissions intake process checklist 24 hours after admission for compliancy. Clinic Director will review new admission process quarterly to assure compliancy.
. "Ongoing compliance will be monitored during quality record reviews. The Clinical Supervisor will address non-compliance in this area during individual supervision. Continued non-compliance will be addressed via the EIP process."
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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
The facility failed to obtained informed, voluntary, written consent before an agent was administered in client record #5.
Client #5 was admitted to methadone treatment on 6/26/18. The informed consent to treatment was signed on 7/2/18.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will conduct a clinical staff training to review and address the policy and procedures of informed, voluntary, and written consents. All clinical staff will have an opportunity to address any questions and/or concerns during the staff clinical training. All clients will sign an informed, voluntary, written consent prior to the administration of an agent.
The Clinical Supervisor will conduct peer reviews quarterly on charts to ensure the written consent policy is maintained.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of client records, the facility failed to provide patient # ' s 10, 12, 13, 14 and 15 with 2.5 hours of psychotherapy per month during the patient ' s first 2 years of treatment.
Client #10 was admitted on January 4, 2018 and was still active at the time of the inspection. In September and October 2018, the client had zero hours of therapy. In August 2018, the client received 1.5 hours of therapy.
Client #12 was admitted on January 18, 2018 and was still active at the time of the inspection. In August 2018, the client received 1.5 hours of group therapy. In October 2018, client received 1.5 hours of group therapy.
Client #13 was admitted on February 27, 2018 and was discharged on August 6, 2018. In April and June of 2018, the client received one hour of therapy.
Client #14 was admitted on March 26, 2018 and was discharged October 2, 2018. In May 2018, the client received 1.5 hours of therapy.
Client #15 was admitted on July 16, 2018 and discharged on October 15, 2018. In September 2018, client received zero hours of therapy.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor and Lead Counselor will make every effort to ensure each patient are provided with an average of 2.5 hours of psychotherapy per month during the patient's first 2 years, 1 hour of which shall be individual psychotherapy and/or additional psychotherapy shall be provided as dictated by ongoing assessment of the patient by conducting monthly ongoing monitoring during quality record reviews.
The Clinical Services Coordinator will conduct a meeting with Clinical Supervisor bi-weekly to ensure patients are receiving the appropriate psychotherapy per month requirements.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
The facility failed to document that the transferring narcotic treatment program was notified of the admission of the patient and initial dose.
Patient #5 was transferred to the facility and was admitted on June 26, 2018. A transfer acknowledgement was not sent to the transferring facility until June 29, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Supervisor will have a training on written transfer policies and procedures to transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient and a transfer acknowledgement form has been completed.
The Clinical Supervisor will review charts monthly to ensure policies are being maintained. The Clinical Supervisor will address non-compliance in this area during individual supervision.
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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
Clinical Services Department will revise the Termination policy to bring the Policy and Procedure in full conformance with the regulations. Project management will review policy and procedure revisions with all staff at the January 2019 staff meeting. |
715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
The facility failed to fully follow through with grievance procedures.
The grievance log book was reviewed on November 19, 2018. The period of January - November 2018 was reviewed. During that time frame, there were a total of eight patient grievances filed that did not have a response or any type of documentation stating the grievances were heard.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director will utilize the 16.1 grievance form that includes the date, location, description of grievance and response of the grievance. The Clinic Director will also utilize the acknowledgment of notification of grievance resolution to ensure the patient's grievance is reviewed and conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
The Clinic Director will ensure the grievance is addressed with patient within 24 hours.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
The facility failed to document that the annual evaluation of each patient's status was reviewed, dated and signed by the medical director.
Client #4 was admitted to treatment on January 14, 2017 and the annual evaluation was completed on January 4, 2018. There was no documentation that the medical director reviewed and signed the annual evaluation.
Client #6 was admitted to treatment on July 2, 2015 and the annual evaluation was completed on July 20, 2018. There was no documentation that the medical director reviewed and signed the annual evaluation.
Client #7 was admitted to treatment on May 29, 2014 and the annual evaluation was completed on May 8, 2018. There was no documentation that the medical director reviewed and signed the annual evaluation.
Client #8 was admitted to treatment on May 1, 2017 and the annual evaluation was completed on May 4, 2018. There was no documentation that the medical director reviewed and signed the annual evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Nurse Manager will collaborate with the Clinical Supervisor to ensure the Medical Director is aware of upcoming patient annual evaluations to review, date, and sign at the beginning of each month.
The Clinic Director will meet with the Nurse Manager and Clinical Supervisor quarterly to assure this procedure is being maintained.
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709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of seven outpatient client records, the facility failed to document type and frequency of treatment and rehabilitation in three of the records reviewed.
Client #10 was admitted on January 4, 2018 and was still active at the time of the inspection. In the client ' s treatment plan dated April 16, 2018, the type of therapy was not documented. The treatment plan states "group or individual therapy ".
Client #13 was admitted on February 27, 2018 and discharged on August 6, 2018. In the client ' s treatment plan dated April 11, 2018, the type of therapy was not documented. The treatment plan states " individual or group every month " .
In addition, the facility failed to document the individual treatment and rehabilitation plan within the first thirty days of admission, as per agency policy.
Client #2 was admitted on January 5, 2018 and the individualized treatment and rehabilitation plan was completed on March 24, 2018.
Client #5 was admitted on June 26, 2018 and the individualized treatment and rehabilitation plan was completed on September 13, 2018.
Client #10 was admitted on January 4, 2018 and the individualized treatment and rehabilitation plan was completed on April 16, 2018.
Client #12 was admitted on January 18, 2018 and the individualized treatment and rehabilitation plan was completed on July 9, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will do a training/review on individual treatment plans to include what written documentation is needed within the treatment plan, how frequent a patient should obtain services, and what type of service is required.
The Clinical Supervisor will conduct peer reviews as well as quarterly checks to ensure procedures are being maintained.
The Clinic Supervisor will update the Clinic Director quarterly on treatment plan compliance.
. "Ongoing compliance will be monitored during quality record reviews. The Clinical Supervisor will address non-compliance in this area during individual supervision. Continued non-compliance will be addressed via the EIP process."
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