INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 4 - 5, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House 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 (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
Based on a review of fire drill records, the facility failed to maintain a fire drill record including the exit route used. In addition, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill records were reviewed on March 4, 2014. The facility failed to maintain a fire drill record including the exit route used during the monthly fire drills conducted from April 2013 through February 2014. In addition, the facility failed to prepare alternate exit routes during the fire drills conducted from April 2013 through February 2014.
The facility director confirmed the findings.
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Plan of Correction
705.28 (d) (1) The clinic Health and Safety Chairperson and Assistant Chairperson, who are responsible for conducting and recording fire drills, were informed of the citation on March 6, 2014. The entire staff was also made aware of the citation. Follow up discussions were held with the Chair and Assistant Chair to assure they are prepared to conduct drills which block specific exits and also record which exits were used during the drill. The fire drill report form will be changed to include exits blocked and exits used. The Health and Safety Chair is responsible for implementing these corrections and the Program Director is responsible for monitoring completion. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of three client records.
The findings include:
Sixteen client records were reviewed on March 4 - 5, 2014. Three records pertained to clients that were involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in client record # 9.
Client # 9 was admitted into treatment on September 15, 2011 and involuntarily terminated from treatment on November 26, 2013. The facility failed to notify client # 9, in writing, of the decision to involuntarily terminate the client's treatment at the project.
The facility director confirmed the findings.
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Plan of Correction
709.33(a) The clinic staff were notified of this citation on March 6, 2014. Clinical staff, Clinical Supervisor and Senior Counselor were trained on March 20, 2014, on the following specific process to utilize in providing involuntarily discharged patients with written notice of the discharge, including the reason for the discharge.
1. Complete an Administrative Withdrawal Notification form for the patient, including the specific reason for discharge.
2. Have the patient review and sign the Administrative Withdrawal Notification form.
3. Provide the patient with a copy of the form, whether or not the patient signs or refuses to sign the form.
4. If patient is discharged immediately from the clinic or leaves the clinic suddenly without receiving a copy of the form, place a copy of the form in the mail to the patient, using an envelope not identified as from Discovery House.
5. If the patient refuses to sign the form, note in the patient's record that a copy of the form was given or mailed to the patient.
Counselors are responsible for implementing this process. The Clinical Supervisor is responsible for monitoring completion of this process.
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