INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 7, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc. - 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 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 8, 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 scheduled 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 8, 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 scheduled 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 limit specific information to be disclosed from the client record to that allowed under 4 Pa. Code Subsection 255.5 (b) in three of eight client records.
The findings include:
Eight client records were reviewed on October 7, 2010. The informed and voluntary consents from the client for the disclosure of information contained in the client record exceeded the limitations on the type and amount of information that can be released to the funding source in three of eight client records.
In client record #5, the facility disclosed methadone dosage information, the discharge summary, the psychosocial evaluation, the medical evaluation, the prescription and HIV/AIDS information to the funding source, which exceeds the limitations imposed under 4 Pa. Code Subsection 255.5(b).
In client record #6, the facility disclosed methadone dosage information, the discharge summary, the psychosocial evaluation, the medical evaluation, the prescription and HIV/AIDS information to the funding source, which exceeds the limitations imposed under 4 Pa. Code Subsection 255.5(b).
In client record #7, the facility disclosed methadone dosage information, the discharge summary, the psychosocial evaluation, the medical evaluation, the prescription and HIV/AIDS information to the funding source, which exceeds the limitations imposed under 4 Pa. Code Subsection 255.5(b).
The facility director acknowledged that this is a consistent problem with staff documentation that she is trying to improve.
This is a repeat citation from the October 8, 2009 licensing inspection.
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Plan of Correction
The Facility Director reviewed the records in question and met with the staff members who incorrectly completed the voluntary consents, and instructed the staff members 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 Supervisor will also review the proper procedure for completion of consents at the weekly group supervision meetings at least bimonthly.
The Facility Director provided the clinical staff with a written resource provided by the federal government on the proper completion of voluntary consents and the limits of 42 CFR regulations.
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. |
709.92(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 client records and discussion with the facility director, the facility failed to update treatment plans at least every 60 days in four of six client records.
The findings include:
Eight client records were reviewed On October 7, 2010. Six of those records required a treatment plan update. The treatment plan update in client records #3, 5 and 7 were completed late. A treatment plan update in client record #2 was not documented.
Client #2 was admitted on 3/25/10. The treatment plan was dated 4/22/10. The first treatment plan update was due to be completed on or before 6/25/10. The first treatment plan update was completed on 6/25/10. The next treatment plan update was due to be completed on or before 8/25/10, but was not dated as being completed until 10/4/10.
Client #3 was admitted on 4/13/10. The treatment plan was dated 6/3/10. The treatment plan update was due to be completed on or before 8/3/10, but was not dated as being completed until 9/2/10.
Client #5 was admitted on 4/22/10. The treatment plan was dated 5/14/10. The treatment plan update was due to be completed on or before 7/14/10, but was not dated as being completed until 7/21/10.
Client #7 was admitted on 3/30/10. The treatment plan was dated 5/3/10. The treatment plan update was due to be completed on or before 7/3/10, but was not dated as being completed until 713/10.
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Plan of Correction
The Clinical Supervisor will audit the list of treatment plans and updates due on a weekly basis during individual supervision. The Clinical Supervisor will monitor the completion of all treatment plans and updates once per week for the next six months to ensure that treatment plans and updates are completed in accordance with program policy and regulations.
The Facility Director will then review the list of treatment plans and updates due on a monthly basis to ensure that documentation is completed on or before the due date. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on a review of client records and discussion with the facility director, the facility failed to document complete medication records in four of five client records.
The findings include:
Eight client records were reviewed on October 7, 2010. Five of those clients were on prescription medication and required documentation of the name of the medication, the dosage prescribed and the frequency of use. The dosage prescribed and frequency of use were not documented in client records #3, 4, 5 and 7.
It was documented in client record #3 that the client was taking Adderall and Lunesta. The dosage and frequency were not documented.
It was documented in client record #4 that the client was taking asthma medication. The name of the medication, dosage and frequency were not documented.
It was documented in client record #5 that the client was taking Humolog and Humilin. The dosage and frequency were not documented.
It was documented in client record #7 that the client was taking Zoloft, Trazedone, Geodon, Bentyl and Vistiril. The dosage and frequency were not documented.
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Plan of Correction
The Facility Director met with the Nurse Manager and the Medical Director to review the regulation and the deficiencies. The Medical Director is now including the required information in his "Physician Documentation of Addiction" note upon admission.
The Facility Director reviewed the deficiency at the general staff meeting in October and explained the expectation that the name of the medication, dosage and frequency should be documented in the biopsychosocial history.
The Clinical Supervisor or designee will conduct random audits of this documentation as part of the monthly chart review process. A minimum of 10 percent of each counselor's caseload will be reviewed each month.
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