INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 3-4, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Center for Behavioral Health - PA dba Discovery House - PA was found to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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
Facility Director will work with the Regional Director and Corporate HR department to develop a policy that is in compliance with the regulation regarding recruitment and hiring.
This will be done by May 30, 2019.
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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.
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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.
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