INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 26-27, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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709.30 (3) 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.
(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.
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Observations
Based on a review of patient records, the facility failed to document written acknowledgement by patients that they have been notified of the right to know the reasons for removing sections of their record in three out of three applicable records.
Patient #1 was admitted on July 12, 2022 and was still active at the time of the inspection.
Patient #2 was admitted on May 17, 2022 and was still active at the time of the inspection.
Patient #4 was admitted on June 8, 2022 and was still active at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Allentown has such policy in place (1.2.1) and we will continue to adhere to such policy in accordance with the DDAP standards. We will be sure to review policies with the auditor on site. All patients are provided with a copy of this policy as evidenced by their signing of the Patient Rights acknowledgement form at admission. Patients are also provided with a copy in their patient handbook which is also acknowledged on the "Patient Orientation" form. |
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 o a review of patient records, the facility failed to document a notification of termination in one out of one applicable records.
Patient #3 was admitted on August 6, 2021 and was discharged on September 8, 2022.
This finding was reviewed with the facility during the licensing process.
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Plan of Correction
Clinic Director and Clinical Supervisor will review termination policy with staff at next staff meeting 11/16/22. New staff will be trained on proper policy and reviewed in team meetings and supervision. Ongoing non compliance will be addressed by the Nurse Manager and Clinic Director individually utilizing the Employee Improvement Plan process.
This will be monitored via Quality Record Review process completed monthly by C.S. |
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 the review of physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients.
During the week of August 21-27, 2022, the patient census was 380. The facility was required to provide at least 38 physician hours. There were 37.25 physician hours documented.
During the week of August 28-September 3, 2022, the patient census was 382. The facility was required to provide at least 38.2 physician hours. There were 38 physician hours documented.
During the week of September 4-10, 2022, the patient census was 379. The facility was required to provide at least 37.9 physician hours. There were 32 physician hours documented.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will ensure that the Program Physician(s) provide at least 1 hour per week onsite for every ten patients. A Physician schedule has been developed as of 11/01/2022 and will be submitted to the medical staff monthly to ensure there is adequate coverage. There is consideration of hiring another physician to assist with those times where there is an anticipated lack of coverage to meet the necessary regulation ratio requirement. The CTC Director will monitor the monthly calendar to ensure there is adequate coverage. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to document an emergency contact in two out of eight records reviewed.
Patient #3 was admitted on August 6, 2021 and was discharged on September 8, 2022.
Patient #7 was admitted on October 4, 2021 and was still active at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
CMS and CD at next case management meeting, November 23, 2022 will review requirements for admissions including emergency contact ROI. CTC will obtain emergency contacts for all patients upon admission. CTC Case Managers will add the ROI at admission and complete with the patient. CD, CS, and CMS will review with case managers. New staff will be trained on proper policy and reviewed in team meetings and supervision upon hire. Ongoing non-compliance will be addressed by the Case Management Supervisor and Clinic Director individually utilizing the Employee Improvement Planning process.
PT #3 has successfully discharged. PT #7 was rectified on 11/4/22. |
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
Based on a review of client records, the facility failed to provide patient with 2.5 hours of psychotherapy per month during the patient's first two years, 1 hour of which shall be individual psychotheray in five out of six applicable records reviewed.
Patient #1 was admitted on July 12, 2022 and was still active at the time of the inspection. In August 2022, the patient received two hours of group therapy and .5 hours of individual therapy in September.
Patient #2 was admitted on May 17, 2022 and was still active at the time of the inspection. In July 2022, the patient received .5 hours of individual and 2 hours of group therapy. In September 2022, the patient received .5 hours of individual and 2 hours of group therapy.
Patient #3 was admitted on August 6, 2021 and was discharged on September 8, 2022. In July 2022, the patient received zero hours of therapy. In August the patient 1 hour of group therapy.
Patient #4 was admitted on June 8, 2022 and was still active at the time of the inspection. In July 2022, the patient received 3 hours of group therapy. In August 2022, the patient received .5 hours of individual and 1 hour of group therapy.
Patient #7 was admitted on October 4, 2021 and was still active at the time of the inspection. In July 2022, the patient had zero hours of therapy. In September 2022, the patient had .5 hours of individual and 3 hours of group therapy.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
CTC Clinic Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services for all patients within this narcotic treatment program. The Clinical Supervisor reviewed the requirements for counseling services with all counselors on November 14,2022. As of November 14,2022, each counselor will run their Direct Services Analysis reports in the EMR and turn into the Clinical Supervisor for verification of patient compliance to psychotherapy. The Clinical Supervisor will review the reports in individual and group supervision monthly.
Patients that missed counseling will be held to meet with a member of the clinical team prior to medicating to address issues of counseling non-compliance. Continued issues of counseling non-compliance after multiple intervention attempts will be brought to the team for discussion of next steps. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to complete an annual physical examination given by the narcotic treatment physician which includes an annual reevaluation by the narcotic treatment physician in three out of three applicable records.
Patient #3 was admitted on August 6, 2021 and was discharged on September 8, 2022. An annual physical examination was due no later than August 6, 2022; however, none was completed.
Patient #5 was admitted on April 9, 2018 and was still active at the time of the inspection. An annual physical examination was due no not later than April 9, 2022; however, it was completed on April 28, 2022.
Patient #7 was admitted on October 4, 2021 and was still active at the time of the inspection. An annual physical examination was due no later than October 4, 2022; however, it was completed on October 5, 2022.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 31, 2022 and November 2, 2021 licensing inspections.
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Plan of Correction
The Nursing Manager will pull the services due report in the EHR for the upcoming month and schedule annual physicals with the physicians and patients. Holds will be placed on patients to not only remind them of upcoming appointments, but also on the day of their appointment. CTC director will also monitor compliance weekly and address non-compliance with the Nurse Manager/Physician as needed. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to complete an annual evaluation of each patient ' s status by the patient's counselor in two out of three applicable records.
Patient #3 was admitted on August 6, 2021 and was discharged on September 8, 2022. An annual evaluation was due no later than August 6, 2022; however, none was completed.
Patient #7 was admitted on October 4, 2021 and was still active at the time of the inspection. An annual evaluation was due no later than October 4, 2022; however, it was completed on October 25, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Beginning 11/21/22, Clinical Supervisor will monitor Annual Evaluations due on a weekly basis in supervision with staff. This will be accomplished by utilizing the Services Due report via the EMR for respective staff. Weekly review of evaluations will be completed by the CS to ensure completion and signatures will be verified. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of patient records, the facility failed to document a preliminary treatment plan within the timeframe stated in the policy and procedure manual in one out of three applicable records reviewed. The facility's policy and procedures manual states in section 7.1.4 that the preliminary treatment plan must be completed by day seven following admission.
Patient #4 was admitted on June 8, 2022 and the preliminary treatment plan was completed on June 29, 2022.
This finding was reviewed with the facility during the licensing process.
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Plan of Correction
Beginning 11/21/22, all preliminary treatment and rehabilitation plans due will be reviewed weekly by the Clinical Supervisor with respective staff. CS will review plans for timeliness and patient input via the EMR. Any issues will be addressed with staff in weekly supervision ongoing. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on the review of patient records, the facility failed to develop an individual treatment plan within the timeframe stated in the policy and procedure manual in two out of three applicable records. The facility's policy procedure manual states in section 7.1.4 that the comprehensive treatment plan must be completed between days 8-30.
Patient #1 was admitted on July 12, 2022 and was still active at the time of the inspection. An individual treatment plan was due no later than August 12, 2022; however, it was completed on August 18, 2022.
Patient #2 was admitted on May 17, 2022 and was still active at the time of the inspection. An individual treatment plan was due no later than June 17, 2022; however, it was completed on June 30, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Beginning 11/21/22, all preliminary treatment and rehabilitation plans due will be reviewed weekly by the Clinical Supervisor with respective staff. CS will review plans for timeliness and patient input to include short and long-term goals for treatment as formulated by both staff and client via the EMR. Any issues will be addressed with staff in weekly supervision ongoing. |
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
Based on a review of patient records, the facility failed to document treatment plan updates within the regulatory timeframe in five out of seven applicable records reviewed.
Patient #3 was admitted on August 6, 2021 and discharged on September 8, 2022. A treatment plan update was completed on April 16, 2022 and the next update was due no later than June 16, 2022; however, it was completed on June 21, 2022. The next update was due no later than August 21, 2022; however, none was completed.
Patient #5 was admitted on April 9, 2018 and was still active at the time of the inspection. A treatment plan update was completed on April 8, 2022 and the next update was due no later than June 8, 2022; however, it was not completed until June 10, 2022.
Patient #6 was admitted on December 4, 2020 and discharged on October 12, 2022. A treatment plan update was completed on June 11, 2022 and the next update was due no later than August 11, 2022; however, it was not completed until August 24, 2022.
Patient #7 was admitted on October 4, 2021 and was still active at the time of the inspection. A treatment plan update was completed on August 3, 2022 and was due no later than October 3, 2022; however, it was not completed until October 11, 2022.
Patient #8 was admitted on November 29, 2019 and was still active at the time of the inspection. A treatment plan update was completed on July 8, 2022 and the next update was due no later than September 8, 2022; however, it was not completed until September 28, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Treatment plan updates will be completed a minimum of every 60 days. The Clinical Supervisor will review the services due report in SMART monthly and address non-compliance in Clinical Supervision. Further, compliance in this area will also be reviewed by the Clinical Supervisor during all Quality Record Reviews. Non-compliance in this area will be documented in writing and employee improvement plans will be presented if warranted. |
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 the review of client records, the facility failed to document an aftercare plan information within the timeframe stated in the policy and procedure manual in one out of one applicable records reviewed.
Patient #6 was admitted on December 20, 2020 and discharged on October 12, 2022. There was no aftercare plan documented in the record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will continue to conduct weekly and monthly reviews of all services necessary, including that of post treatment documentation such as, discharge summaries, after care planning, and follow-up contacts on both successful and unsuccessful discharges. Follow up contacts will be assigned by the Clinical Supervisor to either the primary clinician and/or the Admissions team and these contacts will be documented within the EMR in order to meet this regulation. |
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 the review of client records, the facility failed to document follow-up information in one out of three applicable records reviewed. The facility's policy and procedure manual states follow-up will be completed within 30 days.
Patient #3 was admitted on November 13, 2020 and discharged on September 8, 2022. Follow-up was due no later than October 8, 2022; however, it was completed on October 25, 2022.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will continue to conduct weekly and monthly reviews of all services necessary, including that of post treatment documentation such as discharge summaries and follow-up contacts on both successful and unsuccessful discharges. Follow up contacts will be assigned by the Clinical Supervisor to either the primary clinician and/or the Admissions team and these contacts will be documented within the EMR in order to meet this regulation. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for annual physical examinations were submitted and approved by the Department for the March 31, 2022, and November 2, 2021 licensing inspections. Annual physical examinations were again found to be a deficiency in the October 27, 2022, licensing inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Allentown CTC will identify issues with proposed plans of correction as they present and formulate protocols to ensure that repeat citations are avoided in the future. The current plans of correction for this audit period are believed to be attained and maintained with current staffing and policies in place. The Nursing Supervisor will pull the services due report in the EHR for the upcoming month and schedule annual physicals with the physicians. CTC director will also monitor compliance weekly and address non-compliance with the Nurse Supervisor/Physician as needed. |