INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on March 30, 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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709.28 (c) 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.
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Observations
Based on a review of patient records, the facility failed to obtain a consent to release information form prior to releasing information in two out of seven records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Patient #4 was admitted on November 23, 2021 and was still active at the time of the inspection.
Patient #7 was admitted on March 19, 2018 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with confidentiality. The CTC Director & Clinical Supervisor, as well as the RD, will re-review the requirements for release of information and confidentiality documentation, as well as, ensuring all are signed with all staff on 4/18/2022 during group supervision. Clinic Director and Clinical Supervisor will ensure that all release of information forms will indicate a specific purpose of the disclosure to named parties within the ROI. All releases of information will be reviewed for accuracy and that these releases of information are completed in its entirety on a monthly basis. |
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 must 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, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one out of seven records reviewed. In addition, one out of seven patient records had an ROI that was missing what specific information could be disclosed.
Patient #4 was admitted on November 23, 2021 and was still active at the time of the inspection. A release of information form was signed and dated on February 2, 2022 to probation allowed for the release of drug screenings and discharge status.
Patient #6 was admitted on January 26, 2021 and was still active at the time of the inspection. A release of information form signed and dated January 4, 2022 did not list what information could be disclosed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with confidentiality. The CTC Director & Clinical Supervisor, as well as the RD, will re-review the requirements for release of information and confidentiality documentation with all staff 4/18/2022. RD performed an all staff training ROI's on 3/8/2022 during our monthly team meeting. At this time all ROI's have been changed in the EHR to reflect the pertinent information to be released. Clinic Director and Clinical Supervisor will ensure that all release of information forms will indicate a specific purpose of the disclosure to named parties within the ROI. All releases of information will be reviewed for accuracy and that these releases of information are completed in its entirety on a monthly basis. |
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 the review of patient records, the facility failed to document an annual reevaluation by the narcotic treatment physician within the regulatory timeframe in two out of three applicable records reviewed.
Patient #5 was admitted on March 10, 2021 and was still active at the time of the inspection. An annual physical was due on March 10, 2022; however, there was no documentation in the patient's record of it being completed.
Patient #7 was admitted on March 19, 2018 and was still active at the time of the inspection. An annual physical was due on March 19, 2022; however, it was not completed until March 25, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Nursing Supervisor will pull the services due report in the EHR for the upcoming month and schedule annual physicals with the physicians prior to their due date. CTC director will also monitor compliance weekly and address non-compliance with the 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 the review of patient records, the facility failed to document an annual clinical evaluation with all areas of regulation addressed within the regulatory timeframe in three out of three applicable records reviewed.
Patient #5 was admitted on March 10, 2021 and was still active at the time of the inspection. The annual clinical evaluation completed on March 4, 2022 was missing financial management ability documentation.
Patient #6 was admitted on January 26, 2021 and was still active at the time of the inspection. The annual clinical evaluation was due on January 26, 2021; however, there was no documentation in the patient's record of it being completed.
Patient #7 was admitted on March 19, 2018 and was still active at the time of the inspection. The annual clinical evaluation was due on March 19, 2022; however, it was completed on March 28, 2022. In addition, the evaluation was missing financial management ability documentation.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with annual clinical evaluations. Annual Clinical Evaluations include: (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. The CTC Director & Clinical Supervisor will re-review the requirements for clinical evaluations with all counselors on 4/18/2022. Ongoing non-compliance in meeting the Direct Services requirement will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of patient records, the facility failed to document proposed type of support service on individual treatment plans in three out of seven records reviewed.
Patient #1 was admitted on January 26, 2022 and was still active at the time of the inspection. The treatment plan was dated February 22, 2022.
Patient #2 was admitted on January 24, 2022 and was still active at the time of the inspection. The treatment plan was dated February 22, 2022.
Patient #3 was admitted on November 9, 2021 and was still active at the time of the inspection. The treatment plan was dated March 25, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with treatment plans with all counselors on 4/18/2022. Treatment plans must include support services. Additionally the Clinical Supervisor will review treatment plans to ensure support services are included. The Clinical Supervisor will review the reports in individual and group supervision. Ongoing non-compliance in meeting the Direct Services requirement will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of patient records, the facility failed to ensure that the patients received counseling services according to their individual treatment plan in three out of three applicable records reviewed.
Patient #5 was admitted on March 10, 2021 and was still active at the time of the inspection. The treatment plan dated January 4, 2022 indicated one hour of group therapy per week and 30 minutes of individual sessions weekly. There was no documentation of the patient receiving group therapy between January 30 - February 5, February 13-19, and March 6-12, 2022. In addition, there was no documentation that the patient received individual therapy between February 20-26, and March 6-12, 2022.
Patient #6 was admitted on January 26, 2021 and was still active at the time of the inspection. The treatment plan dated January 30, 2022 indicated weekly individual sessions. There was no documentation that the patient received individual sessions between January 30-February 5, February 13-19, February 20-26, February 27-March 5 and March 6-12, 2022.
Patient #7 was admitted on March 19, 2018 and was still active at the time of the inspection. The treatment plan dated January 14, 2022 indicated individual and group sessions weekly. There was no documentation that the patient received individual therapy between January 16-22, January 23 - 29, February 13-19, and March 6-12. In addition, there was no documentation that the patient received group therapy between January 23-29, February 6-12, February 13-19, February 27-March 5, and March 13-19, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services. The CTC Director & Clinical Supervisor will re-review the requirements for counseling services with all counselors on 4/18/2022. Immediately following this meeting, each counselor will run their Direct Services Analysis reports in SMART and turn into the Clinical Supervisor weekly. Additionally the Clinical Supervisor will run the report monthly and send results to the CTC Director and the Director of Quality and Compliance with a plan of action for overall results below the benchmark of 96%. The Clinical Supervisor will review the reports in individual and group supervision. Ongoing non-compliance in meeting the Direct Services requirement will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process. |