INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted on December 29-30, 2020 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-Pottstown 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:
|
Plan of Correction
|
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
|
Observations
Based on a review of personnel records, the faciltiy failed to ensure that the Faciltiy Director met the educational qualifications of the position in one of one applicable personnel records reviewed.
The faciltiy director was hired on August 10, 2020. The facility director had a documented Bachelor's Degree in Therapeutic Rec., which is not a qualifying degree for this position.
These findings were reviewed with facilityI also staff during the licensing process.
|
Plan of Correction
Plan of Correction:
The staff member in question is a highly accomplished professional with over 25 years of comprehensive experience in administration and patient care. With a Bachelor's degree in Recreational Therapy with a concentration in Geriatric care, combined with the 17 years' experience as a Center Director overseeing: Physicians, RN's, LPN's, CNA's, Dietary personnel, Case Mgr.'s and Case Mgr. Supervisors, it is unclear as to how this staff member does not meet the criteria of §704.5(c), specifically, '...or other related field and 3 years of experience in a human service agency.'
To this end, a monthly training plan has been established for the staff member to complete specific SUD related trainings; underway as of January 1, 2021.
Such will be reviewed and documented monthly with the staff member's immediate supervisor which will be documented and retained for future review.
In addition, staff members' immediate supervisor will file for an Exception to §704.5(c) seeking exception for the educational qualifications on January 29, 2021.
As an alternate plan, should the exception not receive favor, staff member will commence with the necessary steps to achieve Certification via the Pennsylvania Certification Board; to be obtained based on the certification schedule.
All such to be available for review upon request.
|
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the facility's January 2020 through November 2020 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
There were no documented fire drills for the months of March, September and November 2020.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Pursuant to the findings under §705.28(d)(1), the Clinic Director conducted a review of all Fire Safety protocols during the staff meeting on 12/30/20. During this training a review of the monthly completion to same was reviewed with all staff.
Such will be documented in the monthly staff meeting agenda and notations and available for review.
Fire Drills will be consistently recorded monthly and will ensure that documentation is added to highlight that the smoke detector used and others on site are operational. Clinic Director or Facility Health & Safety Liaison will review and monitor Fire Safety Log to ensure monthly fire drills are conducted and documented per licensure regulations.
|
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on a review of the facility's January 2020 through November 2020 fire drill logs, the facility failed to maintain a fire drill record that included whether the facility set off a fire alarm or smoke detector during every drill conducted.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Pursuant to the findings under §705.28(d)(7), the Clinic Director conducted a review of all Fire Safety protocols during a staff meeting on 12/30/20.
During this training a review of the importance of and need to document the source used, either fire alarm or smoke detector for each drill conducted.
Such will be documented in the monthly staff meeting agenda and notations and available for review.
Fire Drills will be consistently recorded monthly and will ensure that documentation is added to highlight that the smoke detector used and others on site are operational. Clinic Director or Facility Health & Safety Liaison will review and monitor Fire Safety Log to ensure monthly fire drills are conducted and documented per licensure regulations.
|
715.7(a)(1-2) LICENSURE Dispensing or administering staffing
(a) A narcotic treatment program shall be staffed as follows:
(1) If it operates an automated dispensing system, one full-time nurse or other person authorized by law to administer or dispense a controlled substance shall be available for every 200 patients.
(2) If it operates a manual or nonautomatic dispensing system, one full-time nurse or other person authorized by law to administer or dispense a controlled substance shall be available for every 150 patients.
|
Observations
Based on an adminstrative review and physical plant inspection, the narcotic treatment program failed to maintain an adequate amount of staffing for the administration of a controlled substance. The program operates an automated dispensing system, therefore, one full-time nurse or other person authorized by law to administer or dispense a controlled substance shall be available for every 200 patients.
The census on the date of the inspection was 310 patients; however, there was only one nursing staff present to dose the patients.
These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
On 11/10/20 an additional staff member was hired and on-boarded as part of the nursing dispensing team at Pottstown CTC.
Pottstown CTC is presently in compliance to the regulation and will ensure continued compliance with the ability to maintain a competent staff schedule to same. Additional per diem Nursing staff will be hired/utilized when full-time nursing staff are absent.
|
715.7(b) LICENSURE Dispensing or Administering Staffing
(b) Dispensing time shall be prorated for patient census. There shall be sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.
|
Observations
Based on a physical plant inspection, the program failed to have sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.
There was a census of 310 patients and only one qualified dispensing staff working in the dispensing area. The receptionist was overheard telling the patients that it would be at least a half hour wait time for dosing because there was only one nurse working.
These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
On 11/10/20 an additional staff member was hired and on-boarded as part of the nursing dispensing team at Pottstown CTC.
Pottstown CTC is presently in compliance to the regulation and will ensure continued compliance with the ability to maintain a competent staff schedule to same. Additional per diem Nursing staff will be hired/utilized when full-time nursing staff are absent.
This corrective measure will ensure continued adherence to this regulation and in meeting the needs of Pt.'s served.
Additionally such will be reviewed by the CD during regular meeting with the nursing team and schedule creation review.
|
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.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to provide patients with 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 in nine of fourteen patient records reviewed.
Patient #1 was admitted on December 1, 2020 and was current at the time of the inspection. Patient #1 had no psychotherapy documented in December 2020.
Patient #2 was admitted on September 14, 2020 and was current at the time of the inspection. Patient #2 had 2 hours of individual psychotherapy in November 2020. No other psychotherapy was documented.
Patient #3 was admitted on February 24, 2020 and was current at the time of the inspection. Patient #3 had 30 minutes of individual psychotherapy and 36 minutes of group psychotherapy in December 2020. In November 2020, Patient #3 had 30 minutes of individual psychotherapy and no group psychotherapy. In October 2020, Patient #3 had 60 minutes of individual psychotherapy and no group psychotherapy.
Patient #8 was admitted on April 3, 2019 and was current at the time of the inspection. Patient #8 had three hours of group psychotherapy in November 2020 and December 2020. Patient #8 had no individual psychotherapy documented.
Patient #9 was admitted on February 24, 2020 and was current at the time of the inspection. Patient #9 had 30 minutes of individual psychotherapy and 36 minutes of group psychotherapy in December 2020. In November 2020, Patient #9 had 30 minutes of individual psychotherapy and no group psychotherapy. In October 2020, patient #9 had 60 minutes of individual psychotherapy and no group psychotherapy.
Patient #12 was admitted on March 13, 2019 and was current at the time of the inspection. Patient #12 had 30 minutes of individual psychotherapy and 36 minutes of group psychotherapy in December 2020. In November 2020, Patient #12 had 30 minutes of individual psychotherapy and no group psychotherapy. In October 2020, patient #12 had 60 minutes of individual psychotherapy and no group psychotherapy.
Patient #13 was admitted on May 26, 2020 and was current at the time of the inspection. Patient #13 had no psychotherapy in December 2020. In November 2020, Patient #13 had 45 minutes of individual psychotherapy and no group psychotherapy. In October 2020, patient #13 had 30 minutes of individual psychotherapy and no group psychotherapy.
Patient #15 was admitted on July 21, 2020 and transferred out on October 14, 2020. Patient #15 had 30 minutes of psychotherapy in September 2020. No other psychotherapy for Patient #15 was documented in the record.
Patient #16 was admitted on April 11, 2020 and was discharged on October 23, 2020 for non compliance. Patient #16 had no psychotherapy documented in the record.
These findings were reviewed with program staff during the licensing process.
This is a repeat citation from licensing inspection conducted on November 15, 2019.
|
Plan of Correction
Plan of Correction:
Pursuant to the findings under §715.19(1) the Clinic Supervisor will conduct a monthly review of all psychotherapy services provided to ensure 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. Any deficiencies will be addressed and ameliorated in weekly supervision with staff counselors. During these weekly supervisions/trainings, the Clinical Supervisor will reiterate the necessity of provide 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.
Such will be documented in the monthly and weekly staff meeting agenda and notations will be reviewed by the Clinical Director. These corrective measures will ensure continued adherence to this regulation and will meet the specified counselor hours of our Pt.'s served.
Additionally, two new counselors were hired and on-boarded as part of the clinical team at Pottstown CTC.
Hire dates for counselors:
Counselor 1 - 12/14/20
Counselor 2 - 12/28/20
|