INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 12-14, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, with the inspection also conducted for the approval to use Methadone and Buprenorphine in the treatment of narcotic addiction. Based on the findings of the on-site inspection, Habit OPCO, Inc. - Allentown 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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704.12(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
A licensing renewal inspection was conducted on December 12-14, 2018. Based on a review of the finalized Staffing Requirements Facility Summary Report submitted by the facility during the licensing process, the facility failed to ensure that all FTE counselor caseloads remained at or under 35:1.
Based on the total number of hours per week devoted to clients, and the standard work week of 35 hours, employee # 9 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full-Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by a standard work week of 35 hours.
reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 9 to outpatient client treatment was 22.5 hours per week. As of October 26, 2018, the employee had 32 active clients who were receiving counseling services at a frequency of at least twice per month.
- Employee # 9 (22.5/35 = .6428 FTE *** 32 clients/.6428 FTE = 50/1 caseload)
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinic Director will reassign the appropriate number of patients to qualified staff from the identified employee and maintain the 35:1 ratio requirement. The Director will hire an additional counselor to maintain this regulation. The Clinical Supervisor will monitor the census and staffing ratio prior to assigning new patients to staff to insure regulatory compliance. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility's fire drill records were reviewed on December 14, 2018, for the period of December 2017 - November 2018. The following deficiencies were found during this review:
-The facility failed to document whether the fire alarm or smoke detector was operative during fire drills conducted on December 12, 2017 and November 22, 2018.
-The facility failed to document the number of people in the facility during the fire drill conducted on December 12, 2017.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinic Director will ensure all fire drills are completed in their entirety through monthly review of the documentation beginning January 2019. The CD will review for accuracy prior to signing the form for each month. The documentation will clearly indicate whether the fire alarm or smoke detector was operative during the drill and will consistently indicate the number of participants monthly. |
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
Weekly physician time sheets and client census reports were reviewed on December 12-14, 2018 for the period of July 1, 2018- October 27, 2018. Based on a review of this documentation, the facility failed to provide at least one hour per week onsite for every ten patients.
For the week of July 1, 2018, the reported patient census was 235. The facility was required to provide at least 23.5 onsite physician hours. There were 20 onsite physician hours documented for this week.
For the week of July 22, 2018, the reported patient census was 234. The facility was required to provide at least 23.4 onsite physician hours. There were 20 onsite physician hours documented for this week.
For the week of July 29, 2018, the reported census was 235. The facility was required to provide at least 23.5 onsite physician hours. There were 20.75 onsite physician hours documented for this week.
For the week of August 26, 2018, the census was reported to be 237. The facility was required to provide at least 23.7 onsite physician hours. There were 19 onsite physician hours documented for this week. These findings were reviewed with facility staff during the licensing process.
For the week of September 9, 2018, the census was reported to be 247. The facility was required to provide at least 24.7 onsite physician hours. There were 16.5 onsite physician hours documented for this week.
For the week of September 16, 2018, the census was reported to be 247. The facility was required to provide at least 24.7 onsite physician hours. There were 16.5 onsite physician hours documented for this week.
This was a repeat citation from the November 20-21, 2017 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director, has acquired additional physician hours for the purposes of coverage when the primary MD cannot meet the regulation. The Clinic Director will review the census weekly and monitor the physician schedule to ensure adequate coverage is provided and intakes will be redirected as needed. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Weekly physician time sheets and client census reports were reviewed on December 12-14, 2018, for the period of July 1, 2018 through October 27, 2018. Based on a review of this documentation, the facility failed to provide at least one-third of all required narcotic treatment physician time by a narcotic treatment physician.
For the week of July 1, 2018, the facility was required to provide at least 7.83 hours by the narcotic treatment physician. There were 5 hours documented for the narcotic treatment physician for this week.
For the week of July 22, 2018, the facility was required to provide at least 7.80 hours by the narcotic treatment physician. There were 5 hours documented for the narcotic treatment physician for this week.
For the week of July 29, 2018, the facility was required to provide at least 7.83 hours by the narcotic treatment physician. There were 5.75 hours documented for the narcotic treatment physician for this week.
For the week of August 5, 2018, the facility was required to provide at least 7.80 hours by the narcotic treatment physician. There were 7 hours documented for the narcotic treatment physician for this week.
For the week of August 19, 2018, the facility was required to provide at least 7.96 hours by the narcotic treatment physician. There were 6 hours documented for the narcotic treatment physician for this week.
For the week of August 26, 2018, the facility was required to provide at least 7.90 hours by the narcotic treatment physician. There were 5 hours documented for the narcotic treatment physician for this week.
For the week of September 9, 2018, the facility was required to provide at least 8.16 hours by the narcotic treatment physician. There were 0 hours documented for the narcotic treatment physician for this week.
For the week of September 23, 2018, the facility was required to provide at least 8.26 hours by the narcotic treatment physician. There were 4.5 hours documented for the narcotic treatment physician for this week.
For the week of September 30, 2018, the facility was required to provide at least 8.33 hours by the narcotic treatment physician. There were 5 hours documented for the narcotic treatment physician for this week.
For the week of October 7, 2018, the facility was required to provide at least 8.36 hours by the narcotic treatment physician. There were 5 hours documented for the narcotic treatment physician for this week.
For the week of October 14, 2018, the facility was required to provide at least 8.30 hours by the narcotic treatment physician. There were 5 hours documented for the narcotic treatment physician for this week.
For the week of October 21, 2018, the facility was required to provide at least 8.33 hours by the narcotic treatment physician. There were 5 hours documented for the narcotic treatment physician for this week.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinic Director has acquired additional physician hours to ensure compliance with the regulation of providing at least one-third of required physician time. The CTC Director will monitor the Physician schedule and census weekly to ensure compliance with the regulation and adjust physician/physician assistant hours appropriately. |