INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on December 18-20, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
The facility failed to document a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served and that every effort will be made to hire staff persons representative of that population.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the 2017 licensure inspection.
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Plan of Correction
Facility Director will work with the Regional Director and Corporate HR department to develop a policy that is in compliance with the regulation regarding recruitment and hiring.
This will be done by May, 30, 2019
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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
The facility failed to document that all staff persons received a minimum of 4 hours of TB/STD training.
Staff #5, hired as a counselor on March 27, 2017 was required to complete TB/STD training by March 27, 2018. There was no documentation that staff #5 completed TB/STD training at the time of the inspection, December 18-20, 2018.
Staff #6, hired as a counselor on May 30, 2017 was required to complete TB/STD training by May 30, 2018. There was no documentation that staff #6 completed TB/STD training at the time of the inspection, December 18-20, 2018.
Staff #7, hired as a counselor on June 19, 2017 was required to complete TB/STD training by June 19, 2018. There was no documentation that staff #7 completed TB/STD training at the time of the inspection, December 18-20, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Within the next 90 days Staff 5, 6, 7 will have TB/STD training. This will be provided onsite by using the Department of Health Curriculum.
There was a training held on 12/20/2018 with the Clinical Supervisor and the Clinic Director on the importance of making sure that each new employee has the documented mandatory trainings. This will be monitored by the Clinic Director on a monthly basis through monthly training audits.
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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 must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to document a confidentiality policy and procedure which complies with 4 Pa Code 255.5.
The revised policies and procedures were reviewed. In the "Confidentiality of Patient Records" section, it states that information about suspected violations of elder abuse must be reported; however, suspected elder abuse is not an exception to Pa Code 255.5. In addition, the policy states that Federal laws and regulations do not protect information about a crime committed by a patient or any threat to commit such a crime; however, the state regulations do protect this information. Only if the crime is committed on program premises or against program personnel would it allow the information to be released without a valid consent.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinic Services Department will revise the policy on Confidentiality of Patient records to bring the policy into conformance with the regulations. Project Management will review Policy revisions with staff in the March 2019 all staff meeting.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document written policies and procedures regarding all of the client rights.
The revisions to the policy and procedures manual and client handbook were reviewed. Neither the policy manual nor the client handbook documented 709.30 -
(1) A client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
and
(3) The project, facility or clinical director may temporarily remove portions of the records prior to inspection by the client if the director determines that the information may be detrimental of presented to the client.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the 2017 licensing inspection.
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Plan of Correction
Clinical Services Department will revise the Client Rights policy and procedure and the Patient Handbook to bring the Policy and Patient Handbook into conformance with the regulations. Project Management will review policy and procedure revisions with all staff at the March 2019 staff meeting. |
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
The facility failed to notify the clients, in writing, of the decision to involuntarily terminate them from treatment.
Client #11 was admitted to treatment on February 1, 2018 and involuntarily terminated from treatment on November 7, 2018. There was no written notice of involuntary termination in client record #11.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director will inform staff of the proper procedure to involuntary terminate, which will be a patient must be informed in writing prior to being involuntary terminated. This will be done at the March 2019 staff meeting. This will be monitored thru chart audit conducted by the Clinical Supervisor. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
The facility failed to file a written unusual incident report with the Department within 3 business days following a patient death.
The unusual incident reports were reviewed on December 18, 2018. Patient deaths occurred on April 3, April 30, June 3 and July 30, 2018. There was no documentation that the facility filed an unusual incident report with the Department within 3 business days. Patient death reports were sent on December 16, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director met with and reviewed the requirements for filing an unusual incident report with the auditor. The clinic director reviewed the appropriate sections of the regulations. Daily the clinic director will review the daily incident report log and patient terminations and discharge report to determine if there were any unusual incidents and or deaths, if there are the clinic director will file the appropriate report with the department. This will be monitored by the clinic director on a daily basis as part of their reporting requirements.
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715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to document that female patients had been fully informed of the possible risk to an unborn child from continued use of illicit drugs and from use of, or withdrawal from, a narcotic drug administered in treatment.
Client # 2, a female patient, was admitted into treatment on February 6, 2018. There was no documentation of risk information being provided to client #2.
Client # 6, a female patient, was admitted into treatment on April 10, 2018. There was no documentation of risk information being provided to client #6.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The intake staff and counselors will utilize the Pregnant Patient Acknowledgement of Risk form for all female patients during intake. A training was held with the intake staff and counselors to review the form and explain the importance of reviewing the information with their female patients. This will be monitored monthly by the clinical supervisor through their chart audits.
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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
The facility failed to document that the narcotic treatment physician reviewed dosage levels at least twice per year with each review occuring at least 2 months apart.
Patient records were reviewed on December 18-20, 2018. All of the dose reviews documented in patient records #1, 2, 3, 4, 5 and 6 were completed by the Physician's Assistant.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The medical director or physician on staff will conduct all medication dosing reviews and the reviews will be done at least twice a year. On December 21, 2018 the clinic director, medical director and physician assistant met to discuss the review and reporting of patient medication dosing levels. The medical director will be responsible for monitoring patient records on a monthly basis.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
The facility failed to document in writing that it notified the transferring narcotic treatment program of the client's admission.
Two of the client's reviewed transferred into the facility from other narcotic treatment programs. The receiving facility is required to notify the transferring facility of the client's admission to decrease the chances of duplicate dosing.
Client #1 was admitted to the facility on April 20, 2018. There was no transfer acknowledgment documented in client record #1.
Client #2 was admitted to the facility on February 6, 2018. There was no transfer acknowledgment documented in client record #2.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The nursing staff will be responsible for completing a Patient Transfer Agreement form for all patients that transfer into the clinic and notify the transferring narcotic treatment program of the admission and the date the initial dose was given to the patient. A training with the nursing staff was held on January 11, 2019 to explain the use of the Patient Transfer Agreement form. This will be monitored monthly by the nursing supervisor through their chart audits.
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715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
The facility failed to develop policies and procedures which limited the reasons for involuntary termination to those conditions permitted by regulation. In addition, the policies and procedures should include providing a detoxification of at least 7 days, except when a patient commits or threatens to commit acts of physical violence.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Services Department will revise the Termination policy to bring the Policy and Procedure in full conformance with the regulations. Project management will review policy and procedure revisions with all staff at the March 2019 staff meeting.
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