INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on February 27 - March 1, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Discovery House, 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 the 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 inspection.
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Plan of Correction
Recruitment and hiring policy will be revised to address the recruitment and hiring of staff persons who are appropriate to the population served. Every effort will be made to hire staff persons representative of the population served. Program staff will continue to work with Human Resources Business Partner in the recruitment and hiring of appropriate staff for the project. Clinical Services Department will be responsible for revising the policy. |
704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
The facilty failed to have a full time clinical supervisor for every eight full-time counselors.
At the time of the inspection, the facility had 8 full time counselors and one part-time counselor. There is a clinical supervisor (staff #3) employed at the Facility; however, as documented on the Staffing Requirements Facility Staffing report, she carries a caseload of 10 patients, with 7 of them attending counseling at least twice per month. Her hours are split evenly between counseling and clinical supervision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will reduce and then maintain the reduced patient caseload to ensure she meets the State of PA standard for a full time Clinical Supervisor.
The Director is responsible for ensuring the Clinical Supervisor meets the reduced patient caseload and maintains this status. The Director will audit the caseload monthly to ensure the Clinical Supervisor maintains compliance.
The reduced caseload will go into effect by April 1, 2018 |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
The current clinical supervisor was promoted to her position on January 2, 2017. There was no documentation of the monthly meetings with the facility director for the first 6 months of employment in that position.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
If or whenever a new Clinical Supervisor is hired, the Director will document the monthly meetings for the first 6 months of employment in that position.
The Director is responsible for ensuring the monthly meeting documentation occurs for a minimum of the first 6 months of employment for a Clinical Supervisor.
This practice is effective immediately, March 12, 2018. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
The facility failed to have written project policies and procedures regarding the utilization of volunteers.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Service Department will work to revise the Personnel Policy to include the utilization of volunteers in the project. Program will review policy revision with all staff in the April Staff Meeting.
Clinical Service Department is responsible for the policy development. |
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 policy and procedures manual and client handbook were reviewed. Neither the policy manual nor the client handbook documented 709.30 (4) Clients have the right to appeal a decision limiting access the their records to the director, (5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, or
(6) Clients have the right to submit rebuttal data or memoranda to their own record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Services Department is responsible for the Client Rights Policy and procedure will be revised to include the client's right to appeal a decision limiting access to records to the Director: Client having the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records; clients have the right to submit rebuttal data or memorandum to their own record. Program management will review policy and procedure revision with all staff at the April 2018 staff meeting. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
The facilty failed to document the inspection of the medication storage area at least quarterly.
There was no documentation of inspection of the medication storage area for the 2017 calendar year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Nurse Manager will utilize the "Inspection of Dosing Area" Form monthly to ensure there is documentation to support the inspection of the medication storage area.
The Director will conduct monthly audits to ensure the form is completed monthly.
This practice goes into effect immediately. The Inspection was completed on March 9, 2018 and the Director co-signed the Inspection form. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
The facility failed to develop and policies and procedures to respond to the following unusual incidents:
709.34 (a)
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
(b) (5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State confidentiality laws.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Unusual Incident Policy and procedure will be revised to include how the project will report and respond to a significant disruption of services due to a disaster such as fire, storm, flood, 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.
Policy and procedure will be revised to ensure that the policy and procedure of reporting an unusual incident to an entity is in full compliance with State confidentiality laws.
Program Management will review policy and procedure revisions with all staff at the April 2018 Staff Meeting.
Clinical Services Department is responsible for revising the policy. |
715.20 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.
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Observations
The facility failed to develop complete written transfer policies and procedures.
The policy and procedure manual was reviewed. The policies and procedures did not include that the facility would transfer the patient within 7 days of the request of the patient and 715.20(4).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Transfer policy and procedure will be revised to include: the project will transfer a patient within 7 days of the patients request to transfer.
Program Management will review the revised policy and procedure with all staff at the April 2018 Staff Meeting.
Transfer policy and procedure will be revised to include: the project shall document in writing that the project notified the transferring narcotic treatment program of the admission and the date of the initial dose given to the patient by the receiving narcotic program.
Program Management will review the policy and procedure revisions with all staff at the April 2018 staff meeting.
The Clinical Services Department is responsible for policy revisions. |
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 which included 715.21 (1) (iv).
The policy and procedures manual was reviewed. The policy did not include that a patient may be involuntarily discharged if the patient has failed to follow treatment plan objectives.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Termination Policy and procedure will be revised to include: a patient may be involuntarily discharged from the project if the patient failed to follow treatment plan objectives.
Program Management will review policy and procedure revisions with all staff at the April 2018 Staff Meeting.
Clinical Services Department is responsible for the policy revision. |