INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 5, 2010 through October 6, 2010 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 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 November 7, 2010.
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Plan of Correction
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709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
Based on a review of personnel records and a discussion with the facility director, the facility failed to provide documentation of salary information in all personnel records.
The findings include:
Six personnel records were reviewed on October 5, 2010 for documentation of salary information. Salary information was not provided for review in one of six personnel records.
Personnel record #1 did not include documentation of salary information. This staff person works at the corporate site in Massachusetts. Salary information was requested to be sent to this facility for review by the licensing specialist during the licensing visit. The facility director indicated to the licensing specialist that this request for salary information was refused.
This is a repeat refusal. Salary information for this staff person, the project director, was not provided during the licensing visit that occurred on October 6, 2009 through October 7, 2009 as well.
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Plan of Correction
The Project Director contacted the Director of the Division of Drug and Alcohol Program Licensure. They came to an agreement that for any future licensing visits, the Project Director will send his salary information directly to the Division so that it arrives in time for the inspection. The Facility Director will notify the Project Director immediately upon being informed of any pending licensing visits. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records and a discussion with the facility director, the facility failed to provide documentation of a work performance evaluation in all personnel records.
The findings include:
Six personnel records were reviewed on October 5, 2010 for documentation of work performance evaluations. A work performance evaluation was not provided for review in one of six personnel records.
Personnel record #1 did not include documentation of a work performance evaluation. This staff person works at the corporate site in Massachusetts. A work performance evaluation was requested to be sent to this facility for review by the licensing specialist during the licensing visit. The facility director indicated to the licensing specialist that this request for a work performance evaluation was refused.
This is a repeat refusal. A work performance evaluation for this staff person, the project director, was not provided during the licensing visit that occurred on October 6, 2009 through October 7, 2009 as well.
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Plan of Correction
The Project Director contacted the Director of the Division of Drug and Alcohol Program Licensure. They came to an agreement that for any future licensing visits, the Project Director will send his most recent performance evaluation directly to the Division so that it arrives in time for the inspection. The Facility Director will notify the Project Director immediately upon being informed of any pending licensing visits. |
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 a review of client records and a discussion with the facility director, the facility failed to obtain an informed and voluntary consent for the disclosure of information contained in the client record which included specific information to be disclosed in four of eight client records.
The findings include:
Eight client records were reviewed on October 5, 2010 through October 6, 2010 for documentation of informed and voluntary consents for the disclosure of information. The consents in client records #2, 3, 5 and 8 did not document the specific information to be disclosed.
Client record #2 included consents to release information to the client's primary care physician, to the funding source and to the client's mother. The specific information to be disclosed was not documented on any of these consents.
Client record #3 included consents to release information to the client's primary care physician, to the funding source, to another treatment provider and to the client's mother. The specific information to be disclosed was not documented on any of these consents.
Client record #5 included consents to release information to another treatment provider and to the client's funding source. The specific information to be disclosed was not documented on the consent to the other treatment provider.
Client record #8 included consents to release information to the client's primary care physician, to the funding source, to two other treatment providers and to the client's girlfriend. The specific information to be disclosed was not documented on any of these consents.
The facility director acknowledged that this is a consistent problem with staff documentation that she is trying to improve.
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Plan of Correction
Since all of the voluntary consents in question were completed by the same counselor, the Program Director met with the counselor to review the incorrect consents and to instruct the counselor on the proper completion of consents.
In addition, the next general staff meeting will include a review and instruction on the proper completion of consents. The Clinical Director will also review the proper completion of consents at the weekly group supervision meetings at least bimonthly.
Random monthly chart reviews will be conducted to include an inspection of all voluntary consent forms, and any problems identified will be corrected.
Finally, individual supervisors will review all completed voluntary consent forms with their supervisees for the next 30 days. |
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 a review of client records and a discussion with the facility director, the facility failed to provide documentation of an aftercare plan in one of one client record.
The findings include:
Eight client records were reviewed on October 5, 2010 through October 6, 2010. One client had successfully completed treatment and required an aftercare plan. An aftercare plan was not documented in client record #6.
Client #6 had successfully completed treatment and a written progress note within the client record stated an aftercare plan was completed, however, documentation of an aftercare plan was missing in client record #6.
The facility director checked to make sure all paperwork was filed in this client's record and also spoke with the clinician responsible for this client record. An aftercare plan could not be provided for client record #6.
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Plan of Correction
The Clinical Supervisor will audit the list of discharges weekly. All patients whose discharge status requires an Aftercare Plan will be identified, and the Clinical Supervisor will ascertain that the Aftercare Plan is completed by the counselor. The Aftercare Plan requires supervisory signature, and the Clinical Supervisor or designee will ensure that all Aftercare Plans are completed via his/her signature. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records and a discussion with the facility director, the facility failed to document follow-up information in one of two client records.
The findings include:
Eight client records were reviewed on October 5, 2010 through October 6, 2010. Follow-up information was required in two client records. Follow-up information was not documented in one of these two client records.
According to the facility's written follow-up policy, follow-up will be completed on all clients via telephone. If a client is referred for other treatment services, follow-up will be completed within seven days of the date of the referral. Where a client is not referred, follow-up will be completed within thirty days of the date of discharge.
Client #5 was discharged on 8/31/10. Follow-up information was not documented in client record #5 as of 10/6/10. The facility director indicated follow-up had not been completed.
This is a repeat citation from the October 6, 2009 through October 7, 2009 licensing inspection.
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Plan of Correction
The Clinical Supervisor or designee will review the list of follow ups due during weekly individual supervision. The Clinical Supervisor or designee will monitor the completion of all follow ups once per week for the next six months to ensure that follow ups are completed in accordance with program policy and regulations.
The Facility Director will then review the list of follow ups due on a monthly basis to ensure compliance. |