INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on December 2-3, 2021 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 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employee's #6 and #7 received the minimum of six hours of HIV/AIDS training within the regulatory timeframe.
Employee #6 was hired as a counselor on August 10, 2020 and was due to have communicable disease training no later than August 10, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee #7 was hired as a counselor on November 9, 2020 and was due to have communicable disease training no later than November 9, 20201. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By February 28, 2022 staff # 6 & 7 will have HIV / AIDS training. This will be provided onsite by using the Department of Health Curriculum. This issue will be addressed at the staff meeting in January 2022. It will be stressed to staff that they receive the appropriate mandatory trainings. This will be monitored by the clinical supervisor and the clinic director through monthly training audits |
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
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.
Employee #3 was promoted to clinical supervisor on November 9, 2020 and was still acting in the position at the time of the inspection. Employee #3 was reported to have 15 hours per week devoted to their 34 clients on their caseload.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
The FTE counselor ' s caseload calculation is as follows: 15/40 = .38 (FTE); 34/.38 = 89.4, which equals to a client/counselor ratio of 89:1.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By January 31, 2022 staff # 3 client case load will be below DDAP regulation limit. Two (2) new counselors have been hired to fill open counseling positions in the clinic. Counselor's caseloads will be filled as the new counselor's complete training. Counselor caseloads will be monitored by the clinical supervisor and the clinic director on a monthly basis. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to conduct random urinalysis at least monthly in one out of nine records reviewed.
Patient #6 was admitted on June 21, 2021 and was still active at the time of the inspection. There was no documentation of a urinalysis being done in August 2021.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The nursing staff on-site will conduct an initial drug screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter for each patient. The nursing supervisor will be responsible for monitoring patient records on a monthly basis to make sure all patients are in compliance. . Implementation will begin immediately and reviewed on an on-going basis. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of patient records, the facility failed to review dosage levels at least twice a year in one out of seven applicable patient records.
Patient #3 was admitted on March 2, 2021 and was still active at the time of the inspection. There was no record of a dosage level review in the patient's chart at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The medical director or physician on staff will conduct all medication dosage reviews, the reviews will be done at least twice a year with each review occurring at least two (2) month apart to determine a patients therapeutic dosage. This will be addressed at the staff meeting in January 2022. The medical director will be responsible for monitoring patient records on a monthly basis. |
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 patient records, the facility failed to provide patient with 2.5 hours of psychotherapy per month during the patient's first two years of treatment in two out of five applicable records reviewed.
Patient # 3 was admitted on March 2, 2021 and was still active at the time of the inspection. In November 2021, the patient received 1.5 hours of group therapy on November 8, 2021 and zero hours of individual therapy.
Patient #6 was admitted on June 21, 2021 and was still active at the time of the inspection. In November 2021, the patient did not receive any counseling hours.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All Patients for the first two years will do the required 2.5 hours of counseling per month. Counselors will make every effort to have the counseling completed each month. If the patient does not show a no-show note will be placed in the EMR to show attempts to get the required hours. This will be addressed in the January 2022 counselor staff meeting. This will be monitored by the clinical supervisor and the clinic director.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to document an annual physical examination within the regulatory timeframe in two out of six applicable records reviewed.
Patient #2 was admitted on August 7, 2018 and was still active at the time of the inspection. An annual physical examination was due on August 7, 2021; however, it was not completed until October 4, 2021.
Patient #9 was admitted on September 14, 2020 and was still active at the time of the inspection. An annual physical examination was due on September 14, 2021; however, it was not completed until October 4, 2021.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The physician or physician assistant is responsible for completing the patient's annual physical. The physician or physician assistant will complete the annual physical exam including the full documentation of a re-evaluation on the patient on a timely basis. The clinic director is responsible for compliance with the standard. Implementation will begin immediately and reviewed on an on-going basis. |
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 clinical evaluation within the regulatory timeframe in two out of six applicable records reviewed.
Patient #5 was admitted on December 16, 2016 and discharged on March 9, 2021. An annual clinical evaluation was due on December 16, 2020; however, it was not completed until February 2, 2021.
Patient #8 was admitted on June 11, 2019 and was still active at the time of the inspection. An annual clinical evaluation was due on June 11, 2021. There was no documented of the annual evaluation in the patient's record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
DHBC counselors will perform an annual evaluation of each patient, the review will be documented in the patient's medical record. The medical director will review date and sign the evaluation. This issue will be addressed at the staff meeting in January 2022. This will be monitored by the clinical supervisor during the monthly records review.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of patient records, the facility failed to ensure that the patients received counseling services according to their individual comprehensive treatment plan in four out of nine records reviewed.
Patient #3 was admitted on March 2, 2021 and was still active at the time of the inspection. A treatment plan dated September 1, and November 2, 2021 indicated one hour of individual session and 1.5 hours of group therapy. In November 2021, the patient did not receive one hour of individual therapy.
Patient #5 was admitted on December 16, 2016 and discharged on March 9, 2021. The treatment plan dated December 23, 2021 indicated one hour of therapy per month. In January 2021, the patient did not receive any therapy hours.
Patient #6 was admitted on June 21, 2021 and was still active at the time of the inspection. A treatment plan dated July 29, 2021 indicated one hour of individual therapy and 1.5 hours of group sessions. In November 2021, the patient did not receive any therapy hours.
Patient #7 was admitted on October 15, 2019 and discharged on August 4, 2021. A treatment plan dated April 26, 2021 indicated 30 minutes a month of therapy or one hour every other month. In April, May and June 2021, the patient did not receive any therapy hours.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
DHBC counselors will continually review the individual patient's treatment and rehabilitation plan and provide and provide treatment based on the individual s plan on file in the patient record. The issue will be addressed at the staff meeting in January 2022. This will be reviewed and monitored by the clinical supervisor during the monthly records review.
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