INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 3, 2007 - December 5, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House - CU, 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 and a plan of correction is due on January 9, 2007.
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Plan of Correction
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, one portable space heater was found in a counselors office.
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Plan of Correction
The heater was removed from the facility.Inservices were provided to ensure that no other heater will be in the facility. This will be monitored by the Program Director. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on review of administrative material the annual report failed to include a statement of income and expenses.
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Plan of Correction
The Project Director and the home office will be notified immediately of the need for this document. This will be done by the program director. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on review of the computerized and printed manuals, the governing body failed to include a written plan/procedures for the management of treatment/rehabilitation services for clients. Documentation provided in the manuals was vague and failed to document who, by job title, would develop, approve, monitor, and evaluate the treatment services. The written procedures did not include clear and consistent time frames for clinical documentation and time frames were not documented for all treatment services.
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Plan of Correction
The policy will be reviewed and amended as needed. The director and policy advisor from DH home office will be responsible in ensuring time frames are in place. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on review of client records it was determined in two clinical records, (# 4 and #5), that the project exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b) by releasing information that exceeded those limitations to an insurance company and a juvenile court system. In client record #4, a staff person documented in a progress note that the client's drug screen results could be given to the client for the sole purpose of giving the results of the drug screen to juvenile court system. In client record # 5 an insurance form was documented in the client record demonstrating an authorization by CBHNP to provide services and to bill for those services, but there was no corresponding consent to release form allowing the facility to contact CBHNP.
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Plan of Correction
The clinical supervisor will hold trainings on 255.5 regulations. This will ensure that the project does not exceed the limitations. This will be monitored by the clinical supervisor and sporadic checks will be done by the program director. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on review of the client records it was determined that the facility failed to document whether the client was offered a copy of the consent form. No release form documented in the five client records reviewed, client records # 1, 2, 3, 4, and 5, included a statement that the client was offered a copy of the consent form.
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Plan of Correction
The clinical supervisor will provide trainings on documentation on whether the patients recieve a copy of a consent form. This will be monitored by the clinical supervisor and sporadic checks will be done by the program director |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Based on review of a client record it was determined that facility staff other than the physician changed the dosing time of a medication without an order from the doctor. In client record #4 , documentation was noted in medical notes (date 9/8/07) that the times the client was to receive the medication was changed by staff other than the physician who prescribed the medication. The change of times differed from that of the 1st order by the doctor.
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Plan of Correction
The program director will hold trainings for the medical staff to ensure that only a physician can change the orders. This will be monitored by the program director through medical chart audits. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on review of client records it was determined that the facility failed to document the clients' complete personal history. Personal histories failed to include a complete family history in client records # 1,2, 3, 4 and 5, which represents five of five records reviewed. The legal histories in client records # 1, 4, and 5, or three out of five records reviewed, failed to include how the clients drug and alcohol use impacted their legal history. Some of the legal history consisted of conflicting information. Employment histories were not complete, contained conflicting information, or failed to include why the client lost their jobs, in client records # 2, 3, 4 and 5, or in four out of five client records reviewed . Educational histories in client records # 1, 2, 3, 4 and 5, or five out of five cleint records reviewed were not complete and failed to document information such as why clients quit school and how their drug and alcohol addiction affected their education . Recreational histories were missing or incomplete in client records # 1, 2, 3, 4 and 5, or five out of five records reviewed, failing to indicate whether the clients' recreational activities had been impacted by their drug and alcohol use. Sexual histories were incomplete in client records # 1, 2, 3, 4, and 5, or five out of five client records reviewed.
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Plan of Correction
The clinical supervisor will hold trainings to ensure that all personal history on patients are detailed and complete around the areas of employment, recreation, legal and how their drug and alcohol addiction affected these different areas. The clinical supervisor will monitor to ensure compliance. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on review of client records it was determined that the facility failed to document on the treatment plan the type of treatment and rehabilitation services the clients are to receive. On all treatment plans reviewed in client records # 1, 2, 3 4, and 5, or five out of five records reviewed, type was not documented. The facility offers group, family/couple, and individual counseling, but this was not stated on the comprehensive treatment plans.
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Plan of Correction
The clinical supervisor will hold trainings for the clinical staff to ensure the type of services offered at the facility is documented on the treatment plans. The clinical supervisor will monitor compliance. |
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 a review of client records it was determined that the facility failed to document support services. In client records # 1, 3 and 4, or three out of five records reviewed, no support services were included. In client records # 2 and 5, two out of five records reviewed, agencies that could be support services were included but the facility failed to indicate whether these were support services.
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Plan of Correction
The clinical supervisor will hold trainings to ensure that support services are included and documented in the patient charts. This will be monitored by the clinical supervisor. |
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 review of the client records it was determined that the facility failed to document progress on treatment plan updates. In client records # 3 4, and 5, three out of three records reviewed, treatment plan updates failed to include an assessment of the client's progress in relationship to the stated goals.
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Plan of Correction
The clinical supervisor will hold trainings to ensure that progress is documented on each goal on the treatment plans. The clinical supervisor will monitor compliance. |
709.93(a)(5) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on review of client records it was determined that the facility failed to document the assessment and failed to address issues relative to the treatment plan in client records # 2, 3, 4, 5, 6 and 7, or six out of seven records reviewed.
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Plan of Correction
The clinical supervisor will hold trainings to ensure the assessment addresses the issues reletive to the treatment plans. The clinical supervisor will monitor compliance through chart audits. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on review of client records it was determined that the facility failed to document aftercare plans that included goals with time frames. In client records # 2, 3, 4, 5, 6 and 7, six out of seven records reviewed, the facility failed to document time frames for goals.
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Plan of Correction
The clinical supervisor will hold trainings on aftercare plans to include goals with time frames. Compliance will be monitored by the clinical supervisor through chart audits. |