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 29 & 30, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Discovery House-NC, 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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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
Based on the review of patient records, the facility failed to document an annual evaluation with all areas of regulation addressed within the regulatory timeframe in two out of five applicable records reviewed.
Patient #7 was admitted on November 2, 2000 and was still active at the time of the inspection. The annual evaluation was due no later than November 2, 2022; however, there was no documentation in the patient record that one was completed.
Patient #9 was admitted on October 26, 2018 and was still active at the time of the inspection. The annual evaluation was due no later than October 26, 2022; however, it was not completed until October 28, 2022.
This is a repeat citation from the March 8, 2022 and July 13, 2022 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 12/12/2022, the Clinical Supervisor and the Lead Counselor will monitor the Annual Evaluations for each counselor to ensure the Annual Evaluations are being completed on time. The Clinical Supervisor and the Lead counselor will focus on these records being completed on time during individual supervision and group supervision as well. The Clinical Supervisor and the Lead counselor will also regularly inspect the patient's charts to determine if all notes are completed. |
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 client records, the facility failed to develop a comprehensive treatment and rehabilitation plan with the client within their policy ' s set time frame of 8-30 days of admission in two out of two applicable records.
Client #2 was admitted on October 12, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than November 12, 2022; however, it was not completed until November 14, 2022.
Client # 8 was admitted on August 19, 2022 and discharged on October 6, 2022. A comprehensive treatment plan was due no later than September 7, 2022; however, it was not completed until September 20, 2022.
This is a repeat citation from the March 8, 2022 and July 13, 2022 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 12/12/2022, the Clinical Supervisor and Lead Counselor will monitor all treatment plans prepared by the counselor to ensure the treatment plan is completed by due date. The Clinical Supervisor and Lead counselor will instruct the counselors to complete all treatment plans by due dates, during the individual supervision and during group supervision. They will conduct internal audits to see if these instructions are being carried out. |