INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 27-28, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc.-Allentown, was found to be not 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 paperwork and a review of employee records conducted on November 27, 2017, the facility failed to ensure that a counselor received the required HIV/Aids trainings within one year of hire date.
Employee #7 was hired as a counselor on 5/2/2016. The HIV/Aids training was to be completed by 5/2/2017 but was not documented at the time of the inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
As of 12/22/17, all newly hired staff will complete HIV/AIDS training within the first year of hire, in accordance with the State regulation. Assistant Director will monitor all training requirements on a quarterly basis and report updates to the Clinic Director via a quarterly training report.
As of 11/9/17, Employee #7 has completed the HIV/AIDS training. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of administrative paperwork and a review of employee files conducted on November 27, 2017, the facility failed to ensure that two counselors received the required 25 training hours for the 2016 training year.
Training files were reviewed for the training year from January 1, 2016 through December 31, 2016.
Employee #5 had 7 documented training hours.
Employee #6 had 11.25 documented training hours.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Beginning 1/1/2018, training hours for all staff will be documented by the Assistant Director, via a formalized quarterly training report, and reviewed by the Director quarterly. Staff will be required to complete 8 hours per quarter to ensure 25 hours will be completed by the end of the calendar year. In addition, the Clinical Supervisor will provide one 2 hour in-house training per quarter to aid in the staff development throughout the year. |
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 a review of the Staffing Requirements Facility Summary Report conducted on November 27, 2017, the facility failed to ensure that employees #2, 5, 6 & 7 did not exceed 35 active clients.
Employee #2 works 37.5 hours and has 44 clients yielding a ratio of 41:1.
Employee #5 works 37.5 hours and has 44 clients yielding a ratio of 41:1.
Employee #6 works 37.5 hours and has 49 clients yielding a ratio of 46:1.
Employee #7 works 37.5 hours and has 46 clients yielding a ratio of 43:1.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
As of 12/22/17, Facility Director has hired two additional staff to correct the issue of ratio compliance. Based on the current census and those who meet the criteria of licensure alert 01-14, the facility will meet the 35:1 requirement. The Clinical Supervisor will monitor ratio weekly, when assigning new admissions to counselors. The Facility Director will monitor census weekly to ensure compliance with this regulation and hire additional staff as needed. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection conducted on November 27, 2017, the facility failed to ensure the confidentiality of client records.
A filing cabinet in the first-floor group room was unable to be locked securely and contained group sign-in sheets that, in some cases, clients had written their full names instead of their initials.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
As of 11/29/17, the filing cabinet in question was fixed with an external pad lock to ensure the confidentiality of client records. In addition, Staff was educated as to the importance of monitoring the sign-in sheets with each appointment and having the patients document only their initials each session or group. Sign-in sheets will be reviewed by the Clinical Supervisor and/or Office Manager monthly to ensure compliance. |
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
Facility policy and procedure manual was reviewed on November 27, 2017. The facility's policy failed to include the following elements with regard to client rights:
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 12/4/17, the Project policy regarding Client Rights, and related documents, was revised to include the following:
To inspect their own records, in the presence of the CTC Director/designee. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
a. Clients have the right to appeal a decision limiting access to their records to the director.
b. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
c. Clients have the right to submit rebuttal data or memoranda to their own records.
The policy and procedure manual for the facility has been updated accordingly.
In addition, the client rights form has been updated. All patients will have the revised client rights form presented and signed by 1/31/18. This will be reviewed by the Facility Director to ensure completion at that time.
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of administrative documents and a review of the physician's schedule hours conducted on November 27, 2017, the facility failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.
A schedule was submitted that indicated the hours worked for the physician and the physician extender staff, as well as the patient census, for the weeks from June 4, 2017 through September 30, 2017. The facility was not in compliance for the following weeks:
June 18-24, 2017: census 235, coverage 20 hours
July 2-8, 2017: census 234, coverage 20 hours
August 13-19, 2017: census 231, coverage 20 hours
August 20-26, 2017: census 228, coverage 19 hours
September 3-9, 2017: census 221, coverage 18.5 hours
September 17-23, 2017: census 218, coverage 19.5 hours
September 24-30, 2017: census 218, coverage 19.5 hours
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
As of 12/5/17, the Facility Director and Assistant Director monitor census weekly via EMR reports to ensure doctor hours are sufficient for the current number of patients. Coverage will be provided by an additional Acadia physician when the physician and the physician extender is unable to fulfill their contracted hours in a given week. |
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
Seven client records were reviewed on November 28, 2017, four of which were methadone client records; the facility failed to provide the required one hour of individual therapy per month to client #1.
Client #1 was admitted on 9/26/17 and was an active client at the time of the licensing inspection. Client #1 received only 30 minutes of individual counseling during the month of October 2017.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
As of 12/22/17, the Clinical Supervisor will monitor direct services provided monthly to ensure all active patients are receiving the mandatory 2.5 hours of clinical services. In addition, all staff will be educated in supervision as to the importance of documenting all "no show" notes, in an effort to demonstrate the attempt to engage patients in weekly sessions and/or groups. |
709.92(a) 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:
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Observations
Seven client records were reviewed on November 28, 2017, four of which were methadone client records; the facility failed to develop the comprehensive treatment plan with clients #2 & 5.
Client #2 was admitted on 3/23/17 and was an active client at the time of the licensing inspection. A comprehensive treatment plan was documented on 4/23/17 however it was not signed by the client until 7/11/17.
Client #5 was admitted on 2/20/17 and discharged on 9/15/17. A comprehensive treatment plan was documented on 4/5/17 however it was not signed by the client and there was no documentation that it had been developed with the client.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
As of 12/5/17, all Counselors print the services due report weekly. Treatment plan updates will be completed every 60 days and monitored via this report. Appointments to review updated treatment plan goals/objectives or to complete a treatment plan with the patient will be scheduled accordingly by Counselors. Appointments not kept by patients will be documented in the EMR under "no show treatment plan appointment." Services due reports will be reviewed in supervision with the Clinical Supervisor to ensure timeliness of documentation. In addition, treatment plan development with the patients will be documented accordingly in the EMR and this requirement will be reviewed during bi-weekly supervision with each counselor. |
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
Seven client records were reviewed on November 28, 2017, four of which were methadone client records; the facility failed to specify the type and frequency of treatment on the comprehensive treatment plan in client records #2, 4, 5 & 7.
Client #2 was admitted on 3/23/17 and was an active client at the time of the licensing inspection. The comprehensive treatment plan was documented on 4/23/17.
Client #4 was admitted on 1/23/17 and discharged on 7/18/17. The comprehensive treatment plan was documented on 2/27/17.
Client #5 was admitted on 2/20/17 and discharged on 9/15/17. The comprehensive treatment plan was documented on 4/5/17.
Client #7 was admitted on 12/13/16 and discharged on 9/5/17. The comprehensive treatment plan was documented on 1/13/17.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will conduct a treatment plan training with all Counselors by 1/31/18. The staff will be re-educated on the appropriate comprehensive plan format, inclusive of specifying type and frequency of treatment, as well as the importance of timely documentation of all treatment plans and updates. |
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
Seven client records were reviewed on November 28, 2017, four of which were methadone client records; the facility failed to update the treatment plan every 60 days in client records, #2, 3, 4, 5 & 7.
Client #2 was admitted on 3/23/17 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 6/23/17; a treatment plan update was due by 8/23/17 but was not documented until 10/30/17.
Client #3 was admitted on 4/25/11 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 12/30/16; a treatment plan update was due by 3/1/17 but was not documented until 3/3/17. Additionally, a treatment plan update was documented on 4/28/17; a treatment plan update was due by 6/28/17 but was not documented until 7/14/17 and another update was due by 9/14/17 but was not documented until 9/22/17.
Client #4 was admitted on 1/23/17 and discharged on 7/18/17. A comprehensive treatment plan was documented on 2/27/17; a treatment plan update was due by 4/27/17 but was not documented until 5/1/17.
Client #5 was admitted on 2/20/17 and discharged on 9/15/17. A treatment plan update was documented on 5/26/17; a treatment plan update was due by 7/26/17 but was not documented until 7/28/17.
Client #7 was admitted on 12/13/16 and discharged on 9/5/17. A treatment plan update was documented on 3/6/17; a treatment plan update was due by 5/6/17 but was not documented until 5/22/17 and another update was due by 7/22/17 but was not documented until 7/31/17.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
As of 12/5/17, all Counselors print the services due report weekly. Treatment plan updates will be completed every 60 days and monitored via this report. Appointments to review updated treatment plan goals/objectives or to complete a treatment plan with the patient will be scheduled accordingly by Counselors. Appointments not kept by patients will be documented in the EMR under "no show treatment plan appointment." Services due reports will be reviewed in supervision with the Clinical Supervisor to ensure timeliness of documentation. |