INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14-16, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site 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 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 administrative documentation, the facility failed to ensure that all staff received a minimum of 6 hours HIV/AIDS training and at least 4 hours of TB, STD and other health related topics within the specified time frames for their respective positions.
The findings include:
Administrative documentation, including the Staffing Requirements Facility Summary Report and personnel records, was reviewed January 15-16, 2014.
Staff # 3 was hired 6-1-11 and was to receive at least 6 hours HIV/AIDS training by 6-1-13. While the training hours were documented, there was no way to determine if the curriculum used was a Department approved curriculum by the trainer.
Staff # 10 was hired 6/29/12 and was to receive at least 6 hours of HIV/AIDS training by 6-29-13. There was no documentation of the training having been completed at the time of the survey.
Staff # 12 has been employed as a counselor for several years. Staff # 12 provided documentation of having received 4 hours total for HIV/AIDS/TB/STD and other health related topics.
Staff # 13 and staff # 14 were listed on the staffing form without hire dates or whether they had received the mandatory training.
The findings were discussed with facility director who provided confirmation of the findings.
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Plan of Correction
The Clinical Supervisor or designee will ensure that all clinical staff receive a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB, STD within the specified time frames for the respective positions. The trainings must utilize a curriculum approved by the Department.
The Clinical Supervisor or designee will also ensure that all current clinical staff that are deficient in their training hours or require training approved by the Department complete their training.
The Director is responsible for ensuring the training hours are completed and completed through an approved State of PA curriculum. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to restrict the disclosure of information to those areas allowed by 4 PA Code 255.5.
The findings include:
Nineteen patient records were reviewed January 14-16, 2014. All patient records required compliance with 42 CFR and 4 PA Code 255.5 regarding confidentiality. Patient record # 16 contained a signed release allowing urine drug results be released to a government agency that is restricted under 4 PA Code 255.5 on November 5, 2013.
This is a repeat deficiency from the April 2013 licensing inspection.
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Plan of Correction
The Clinical Supervisor or designee will conduct an in-house training to review the restrictions on the disclosure of information to areas allowed by 4 PA Code 255.5 by 3/17/14.
The Clinical Supervisor or designee will conduct an audit of random signed release of information to ensure compliance with the training beginning 3/31/14.
The Director is responsible for ensuring the in-house training occurs by 3/17/14 and the audit of random charts by 3/31/14. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to execute an evaluative composite picture of the client in relationship to the collected historical data in three of four client records reviewed.
The findings include:
Nineteen client records were reviewed January 14-16, 2014. Four client records required a psychosocial evaluation. Client records # 11 and 19 did not contain an evaluative psychosocial evaluation. Client # 18 was admitted August 14, 2013 and did not have a psychosocial evaluation documented in the client record.
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Plan of Correction
The Clinical Supervisor or designee will meet with the Admission Team to review the criteria needed to meet the evaluative composite picture of the collected historical data in the psychosocial evaluation. The meeting will also review the criteria for completion of the psychosocial evlauation ahd the proper documentation in the electronic medical record when a patient does not require a full psychosocial evaluation.
The Clinical Supervisor or designee will conduct the meeting with the Admission Team by 3/15/14 and audit random new admissions to ensure the guidelines are followed. The Clinical Supervisor or designee will provide feedback to the Admission Team on new admissions to ensure the evaluative composite picture meets the State of PA standards.
The Director is responsible for ensuring the meeting occurs by 3/15/14, the implimentation of the guidelines are followed and the chart audits occur. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on the review of patient records, the narcotic treatment program failed to document realistic short and long-term treatment goals in six of eleven patient records.
The findings include:
Nineteen patient records were reviewed January 14-16, 2014. Treatment plans with measurable short and long-term treatment goals were required in seventeen patient records. Eleven patient records were reviewed specifically for treatment plans. Patient records # 1, 10, 11, 13, 18 and 19 all contained treatment plan goals that did not reflect the nature of the problem statement. The problem statement in each patient record was related to their respective drug dependencies. However, the short term goals/objectives for the problem area required that they pay their fee or maintain their insurance coverage. None of the six patient records reflected that payment was an issue at the time of the development of the treatment plan goals.
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Plan of Correction
The Clinical Supervisor or designee will conduct an in-house traiing on how to develop treatment plans with realistic short and long term treatment goals. The training will include but not limited to the appropriate use of each demension and the inclusion of such things as payment of fees or maintainingtheir insurance coverage for use when a problem or potential problem is identified.
The Clinical Supervisor or designee will audit treatment plans to ensure compliance with the State of PA M269 guidelines.
The Director is responsible for ensuring the in-house training occurs by March 11, 2014 and the corrective action is active by March 24, 2014. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services on five of five client records reviewed.
The findings include:
Nineteen client records were reviewed January 14-16, 2014. Five client records were reviewed for documentation of proposed support services on the client's treatment plan. Client records # 1, 11, 13, 18 and 19 had no documentation of proposed support services on the comprehensive treatment plan.
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Plan of Correction
The Clinical Supervisor or designee will provide an in-house training on how to locate local supportive services and incorporate the services into the patient treatment plans where applicible. The in-house training will occur on or before 3/11/14.
The Clinical Supervisor or designee will audit random treatment plans to ensure the clinical staff is utilizing support services to augment treamtent beginning 3/31/14.
The Director is responsible for ensuring the in-house training is completed by 3/11/14 and the random audits occur beginning 3/31/14. |