INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on May 4, 2023 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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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 of treatment in two out of six applicable records reviewed.
Patient #1 was admitted on July 12, 2022 and was discharged on April 27, 2023. In December 2022, the patient was a no show for two individual sessions and did not receive any other therapy. In February, the patient received 1 hour of group therapy and .5 hours of individual therapy.
Patient #6 was admitted on December 5, 2022 and was still active at the time of the inspection. In February, 2023, the patient received only 1 hour of individual therapy.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the October 27, 2022 licensing inspection.
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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 will review the requirements for counseling services with all counselors on June 7, 2023 at our Monthly Team Meeting and will review the end of day counselor checklist created to assist in tracking Pt. engagement. Staff who may require additional training and time management will be identified and offered opportunities to attend to such, along with weekly supervision to review same. CS will monitor to ensure each counselor runs their Direct Services Analysis reports daily and turn into the Clinical Supervisor, along with their end of day checklist as verification to 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. |
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 three out of four 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 #5 was admitted on January 18, 2023 and was still active at the time of the inspection. An individual treatment plan was due no later than February 17, 2023; however, it was completed on February 28, 2023.
Patient #6 was admitted on December 5, 2022 and was still active at the time of the inspection. An individual treatment plan was due no later than January 4, 2023; however, it was completed on February 17, 2023.
Patient #9 was admitted on February 17, 2023 and was still active at the time of the inspection. An individual treatment plan was due no later than March 19, 2023; however, it was completed on March 23, 2023.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the October 27, 2022 licensing inspection.
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Plan of Correction
Beginning 5/23/2023, all preliminary treatment and rehabilitation plans due will be reviewed daily and weekly by the Clinic Director and Clinical Supervisor with respective staff; also reviewing such daily with the counselor end of day checklist submission and review with CS. 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 ongoing weekly supervision. |
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 three out of six applicable records reviewed.
Patient #1 was admitted on July 12, 2022 and discharged on April 27, 2023. A treatment plan update was completed on November 15, 2022 and the next update was due no later than January 15, 2023; however, it was completed on February 15, 2023.
Patient #3 was admitted on November 16, 2020 and was discharged on February 21, 2023. A treatment plan update was completed on October 26, 2022 and the next update was due no later than December 26, 2022; however, none was completed.
Patient #4 was admitted on April 25, 2022 and was still active at the time of the inspection. A treatment plan update was completed on November 30, 2022 and the next update was due no later than January 30, 2023; however, it was not completed until February 27, 2023.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the October 27, 2022 licensing inspection.
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Plan of Correction
Treatment plan updates will be completed timely based on patients level of care and needs, with the minimum being every 60 days. The Clinical Supervisor will review the services due report in SMART with each of their reports daily during the end of day process with weekly reviews during supervision using the weekly time frame. Areas requring additional attention will be discussed and documented during regular clinical supervision. CS will review with counseling staff due dates daily to ensure compliance. 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 #2 was admitted on September 9, 2021 and discharged on December 30, 2022. There was no aftercare plan documented in the record.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the October 27, 2022 licensing inspection.
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Plan of Correction
The Clinical Supervisor will continue to conduct daily, weekly, and monthly reviews of all services required utilizing the services due report in the EMR; including 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 counselor and/or the Case mgmt. or admissions team. All such contacts will be documented within the EMR to ensure regulatory compliance. Aftercare planning will begin during patient's acclimation and admission to treatment and care. |
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 two applicable records reviewed. The facility's policy and procedure manual states follow-up will be completed within 30 days.
Patient #2 was admitted on September 9, 2021 and discharged on December 30, 2022. There was no follow up documented in the record.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the October 27, 2022 licensing inspection.
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Plan of Correction
The Clinical Supervisor will continue to conduct daily, weekly and monthly reviews of all services required, including post treatment documentation, such as discharge summaries and follow-up contacts on both successful and unsuccessful discharges. Follow up contacts are required to be completed by the primary counselor assigned to the patient's care. Any edits to such will be made by either the Clinical Supervisor or the Clinic Director in the event such reassignment is required at the point of patient transition/discharge to another care team member who will document such contact(s) in the EMR per regulation §709.93(a)(11). |