INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on December 5-7, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Discovery House-NC, 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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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
A review of the fire drill logs was conducted on December 7, 2012. The fire drills conducted from December 2011 to November 2012 were reviewed. The facility did not document alternate exits used during the May 31, June 13, July 13, August 21, October 24 and November 23, 2012 fire drills
The Facility Director was interviewed on December 7, 2012 and confirmed the findings.
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Plan of Correction
Meeting will be held with the health and safety team to discuss the health and safety regulations in regards to alternate exits being used during the monthly fire drills to plan for alternate exit route during the monthly fire drills. The Program Director and Health and Safety captain will monitor the fire drills to make sure they are done according to regulations using alternate exits. |
709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
Based on a review of the facility's policy and procedures, the corporate Bylaws and Board Meeting Minutes, the facility failed to document that the duties of the governing body included selecting a project director.
The findings included:
The facility's policy and procedures, the corporate Bylaws and Board Meeting Minutes were reviewed on December 5-7, 2012. There was no documentation that the duties of the governing body included selecting a project director.
The Facility Director was interviewed on December 7, 2012 and confirmed the findings.
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Plan of Correction
Discovery House policy states the Governance Authority/Board of Directors will ensure compliance with all applicable legal and regulatory requiremets relating to the corporaation etitiy. According to the 709's there is a need for a governing body which duties will include but not limited to selecting the project director this Discovery House Policy conmlies with this regulation. |
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 a review of the annual report, the facility failed to make an annual report available to the public which included a financial statement of expenses.
The findings include:
The annual report for the 2011 fiscal year was reviewed on December 5-7, 2012. The annual report did not include a financial statement of expenses.
The Facility Director was interviewed on December 7, 2012 and confirmed the findings.
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Plan of Correction
A request has been submitted to the Home office th have the financial statement of expenses added to the next Annual Report and all annual reports in the future. This will be followed up by the Program Director. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on the review of the policy and procedure manual, the facility failed to develop policies which comply with 4 Pa. Code subsection 255.5.
The findings include:
The policy and procedure manual was reviewed on December 5-7, 2012. The facility's confidentiality policy is inconsistent with 4 Pa. Code subsection 255.5(a)(7). Facility policy states: "...in the event that an insurance company, health or hospital plan remains dissatisfied with the content of the information released with regard to a client in accordance with this paragraph, such insurance company, health or hospital plan may apply to the Executive Director for additional information. With the consent of the client, and upon approval by the Executive Director, said information may be released..." This Facility policy is referring to the Executive Director of Discovery House Inc., while the regulation refers to the Secretary of the Department of Drug and Alcohol Programs.
The Facility Director was interviewed on December 7, 2012 and confirmed the findings.
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Plan of Correction
The Program Director will submit to have the language clarified in policy to refer to the Executive Director as the (Secretary of the Department of Drug and Alcohol Programs), not the Executive Director of Discovery House, The POC will be followed up by the Program Director. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the facility failed to document that the client was notified, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of two client records.
The findings include:
Sixteen client records were reviewed on December 5-7, 2012. Two client records reviewed had been involuntarily terminated. The facility did not document that the client was notified, in writing, of a decision to involuntarily terminate the client's treatment at the project in client record # 11.
Client # 11 was admitted on February 4, 2012 and involuntarily discharged on July 29, 2012. There was no documentation that the client was notified, in writing, of a decision to involuntarily terminate the client's treatment at the project.
The Facility Director was interviewed on December 5, 2012 and confirmed the findings.
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Plan of Correction
An in-service conducted by the clinical supervisor will be held with all associates explaining the regulation on involuntary termination. Associates will be instsructed to make sure all patients involuntarily terminated must be notified in writing and receive a copy of the termination notification. This will be followed up by auditing the involuntary patient charts by the clinical supervisor and director. |
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 document psychosocial evaluations that included the clients assets/strengths, support systems, coping mechanisms, negative factors and the counselor conclusions/ impressions in seven of ten client records.
The findings include:
Sixteen client records were reviewed on December 5-7, 2012. Ten client records were reviewed for the completion of a psychosocial evaluation. The facility did not document psychosocial evaluations that included the clients assets/strengths, support systems, coping mechanisms, negative factors and the counselor conclusions/ impressions in client records # 1, 4, 5, 6, 8, 9 and 10.
Client # 1 was admitted on November 9, 2012. The psychosocial evaluation, completed on November 16, 2012 consisted of a summary of the historical data collected and statements of what the client reported without a clinical evaluation of the information.
Client # 4 was admitted on June 12, 2012. The psychosocial evaluation, completed on June 14, 2012 consisted of a summary of the historical data collected and statements of what the client reported without a clinical evaluation of the information.
Client # 5 was admitted on September 10, 2012. The psychosocial evaluation, completed on September 17, 2012 consisted of a summary of the historical data collected and statements of what the client reported without a clinical evaluation of the information.
Client # 6 was admitted on July 20, 2012. The psychosocial evaluation, completed on July 23, 2012 consisted of a summary of the historical data collected and statements of what the client reported without a clinical evaluation of the information.
Client # 8 was admitted on June 25, 2012. The psychosocial evaluation, completed on July 2, 2012 consisted of a summary of the historical data collected and statements of what the client reported without a clinical evaluation of the information.
Client # 9 was admitted on September 11, 2012. The psychosocial evaluation, completed on December 7, 2012 consisted of a summary of the historical data collected and statements of what the client reported without a clinical evaluation of the information.
Client # 10 was admitted on August 7, 2012. The psychosocial evaluation, completed on August 16, 2012 consisted of a summary of the historical data collected and statements of what the client reported without a clinical evaluation of the information.
The Facility Director was interviewed on December 7, 2012 and did not dispute the findings.
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Plan of Correction
The Clinical Supervisor will conduct a training on the psychosocial evaluation. Counselor will be given examples of the documention needed to be included in the assessment, including the patients assets strengths, supoort systems, coping mechanisms, negative factors and the counselor conclusions/impressions. The clinical supervisor and lead counselor will sparadically audit charts for 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 a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services in seven of ten client records.
The findings include:
Sixteen client records were reviewed on December 5-7, 2012. Ten client records included an individual treatment and rehabilitation plan. The facility failed to document the type and frequency of treatment and rehabilitation services in client records # 2, 4, 5, 6, 7, 9 and 10.
Client # 2 was admitted into treatment on July 3, 2012. An individual treatment and rehabilitation plan was developed with the client on July 12, 2012. The treatment plan did not document the type or frequency of treatment and rehabilitation services.
Client # 4 was admitted into treatment on June 12, 2012. An individual treatment and rehabilitation plan was developed with the client on July 11, 2012. The treatment plan did not document the type or frequency of treatment and rehabilitation services.
Client # 5 was admitted into treatment on September 10, 2012. An individual treatment and rehabilitation plan was developed with the client on October 6, 2012. The treatment plan did not document the type or frequency of treatment and rehabilitation services.
Client # 6 was admitted into treatment on July 20, 2012. An individual treatment and rehabilitation plan was developed with the client on August 24, 2012. The treatment plan did not document the type or frequency of treatment and rehabilitation services.
Client # 7 was admitted into treatment on October 5, 2012. An individual treatment and rehabilitation plan was developed with the client on November 4, 2012. The treatment plan did not document the type or frequency of treatment and rehabilitation services.
Client # 9 was admitted into treatment on September 11, 2012. An individual treatment and rehabilitation plan was developed with the client on October 12, 2012. The treatment plan did not document the type or frequency of treatment and rehabilitation services.
Client # 10 was admitted into treatment on August 7, 2012. An individual treatment and rehabilitation plan was developed with the client on September 7, 2012. The treatment plan did not document the type or frequency of treatment and rehabilitation services.
The Facility Director was interviewed on December 7, 2012 and confirmed the findings.
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Plan of Correction
The clinical supervisor will conduct an in-service to instruct the counselor that patient individual treatment and rehabilation plan must include type and frequency fo the treatment and rehabilation services. This will be monitored by the Clinical Supervisor and Lead Counselor through chart audits. |
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 the review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in seven of ten client records.
The findings include:
Sixteen client records were reviewed on December 5-7, 2012. Ten client records were reviewed for compliance that counseling services were provided according to the individual treatment and rehabilitation plan. The facility did not assure that counseling services were provided according to the individual treatment and rehabilitation plan in client records # 2, 4, 5, 6, 7, 9 and 10.
Client # 2 was admitted into treatment on July 3, 2012. An individual treatment and rehabilitation plan was developed with the client on July 12, 2012. The treatment plan did not document the type or frequency of treatment and rehabilitation services therefore, it could not be determined that the client was provided services according to the individual treatment and rehabilitation plan.
Client # 4 was admitted into treatment on June 12, 2012. An individual treatment and rehabilitation plan was developed with the client on July 11, 2012. The treatment plan did not document the type or frequency of treatment and rehabilitation services therefore, it could not be determined that the client was provided services according to the individual treatment and rehabilitation plan.
Client # 5 was admitted into treatment on September 10, 2012. An individual treatment and rehabilitation plan was developed with the client on October 6, 2012. The treatment plan did
not document the type or frequency of treatment and rehabilitation services therefore, it could not be determined that the client was provided services according to the individual treatment and rehabilitation plan.
Client # 6 was admitted into treatment on July 20, 2012. An individual treatment and rehabilitation plan was developed with the client on August 24, 2012. The treatment plan did not document the type or frequency of treatment and rehabilitation services therefore, it could not be determined that the client was provided services according to the individual treatment and rehabilitation plan.
Client # 7 was admitted into treatment on October 5, 2012. An individual treatment and rehabilitation plan was developed with the client on November 4, 2012. The treatment plan did not document the type or frequency of treatment and rehabilitation services therefore, it could not be determined that the client was provided services according to the individual treatment and rehabilitation plan.
Client # 9 was admitted into treatment on September 11, 2012. An individual treatment and rehabilitation plan was developed with the client on October 12, 2012. The treatment plan did not document the type or frequency of treatment and rehabilitation services therefore, it could not be determined that the client was provided services according to the individual treatment and rehabilitation plan.
Client # 10 was admitted into treatment on August 7, 2012. An individual treatment and rehabilitation plan was developed with the client on September 7, 2012. The treatment plan did not document the type or frequency of treatment and rehabilitation services therefore, it could not be determined that the client was provided services according to the individual treatment and rehabilitation plan.
The Facility Director was interviewed on December 7, 2012 and confirmed the findings.
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Plan of Correction
The Clinical Supervisor will conduct and in-service explaining the regulation of individualized treatment planning. She will discuss the audit results and how we did not meet the regulation. Counselors will be giving examples of proper treatment plan and how to individulize them according to each patient needs. This will be monitored by the clinical supervisor and lead counselor through individual supervision and chart audits. |