INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 18, 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 HA 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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704.12(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 #7 was hired as a counselor on January 8, 2018 and was still acting in that position. Employee #7 was reported to have 32 hours per week devoted to their 35 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: 32/40 = .8(FTE); 35/.8= 43.75, which equals to a client/counselor ratio of 43:1.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will keep client/staff ratios at or below the regulation limit of 35/1. Clinic Director and Clinical Supervisor will review all counselor caseloads once a week to ensure the regulation limit is maintained. Clinical Supervisor will adjust counselor caseloads that are found out of compliance during these weekly reviews. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to document an emergency contact in one out of ten records reviewed.
Patient #8 was admitted on May 29, 2014 and was still active at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Emergency contact releases will be completed upon admission for all Patients. Clinical Supervisor will review all admission charts daily to ensure emergency contact releases are being completed. Pt #8's emergency release was updated 11/7/22. |
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 the review of patient records, the facility failed to obtain and document results of a random urinalysis each month in two out of seven applicable records reviewed.
Patient #5 was admitted on May 10, 2022 and was still active at the time of the inspection. There was no documentation of a monthly urinalysis in July 2022.
Patient #6 was admitted on December 29, 2022 and discharged on September 1, 2022. There were no documented results of a monthly urinalysis in June 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility will obtain and document the results of random urinalysis each month for all Patients. Nurse Manager will review all urinalysis results weekly to ensure requested specimens have been provided. Pt's that have not provided a specimen when requested will be required to provide a Nurses Forced Test. Clinic Director and Nurse Manager will review pending urinalysis results with Clinical Science Laboratory bi-weekly to ensure those results are uploaded and copies of the results are sent to the facility. |
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 client 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 one out of three applicable records reviewed.
Patient #5 was admitted on May 10, 2022 and was still active at the time of the inspection. In August 2022, the patient received one hour each of individual and group therapy.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility will provide all Patient's with 2.5 hours of psychotherapy per month during the Patient's first 2 years of treatment. Counselors will provide their monthly deficiency reports to Clinical Supervisor for review and to develop plans of action to ensure all Patients complete monthly counseling requirement. Clinical Supervisor will review these services with the counselors during individual and group supervision. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of patient records, the facility failed to document treatment plan updates within the regulatory timeframe in seven out of eight records reviewed.
Patient #2 was admitted on May 27, 2022 and was still active at the time of the inspection. A treatment plan update was completed on July 22, 2022 and was due no later than September 22, 2022; however, it was not completed until September 23, 2022.
Patient #3 was admitted on March 17, 2017 and was still active at the time of the inspection. A treatment plan update was completed on March 14, 2022 and the next update was due no later than May 14, 2022; however, it was not completed until May 16, 2022.
Patient #5 was admitted on May 10, 2022 and was still active at the time of the inspection. A treatment plan update was completed on July 5, 2022 and the next update was due no later than September 5, 2022; however, it was not completed until September 6, 2022.
Patient #6 was admitted on December 29, 2020 and discharged on September 1, 2022. A treatment plan update was completed on February 15, 2022 and the next update was due no later than April 15, 2022; however, it was not completed until April 27, 2022.
Patient #8 was admitted on May 29, 2014 and was still active at the time of the inspection. A treatment plan update was completed on July 18, 2022 and the next update was due no later than September 18, 2022; however, it was not completed until September 19, 2022.
Patient #9 was admitted on February 7, 2020 and discharged on August 30, 2022. A treatment plan update was completed on April 5, 2022 and the next update was due no later than June 5, 2022; however, it was not completed until June 7, 2022.
Patient #10 was admitted on April 12, 2019 and was still active at the time of the inspection. A treatment plan update was completed on February 1, 2022 and the next update was due no later than April 1, 2022; however, it was completed on April 4, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility will review and complete treatment and rehabilitation plans every 60 days. The Clinical Supervisor will conduct peer reviews, as well as, quarterly checks to ensure procedures are being maintained.
The Clinic Supervisor will update the Clinic Director quarterly on treatment plan compliance. Ongoing compliance will be monitored during quality record reviews. The Clinical Supervisor will address non-compliance in this area during individual supervision. Continued non-compliance will be addressed via the EIP process."
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