INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on April 21, 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.- 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:
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Plan of Correction
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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 patient 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 client records in three out of seven records reviewed. Additionally, one out of seven client records were missing specific information to be released.Patient #1 was admitted on March 24, 2022 and was still active at the time of the inspection. Consents to release information to the primary care physician, and two funding sources dated March 25, 2022 had "other " checked for information to be disclosed with no specific information to be released.Patient #2 was admitted on November 29, 2021 and was still active at the time of the inspection. A consent to release information to a government agency dated February 17, 2022 allowed for the release of psychiatric evaluation, lab reports, practitioner ' s orders, discharge summary/instructions, treatment/individualized service plan, medication records, alcohol/drug/substance abuse records, dosing history, attendance, and compliance verification. Another consent to release information to a funding source dated February 17, 2022 allowed for psychiatric evaluation, lab reports, practitioner ' s orders, practitioner ' s progress notes, financial/account information, mental health records, billing claims, discharge summary/instructions, treatment/individualized service plan, history/physical, medication records, alcohol/drug/substance abuse records, and ASAM.Patient #3 was admitted on January 31, 2022 and was still active at the time of the inspection. A consent to release information to a funding source dated January 31, 2022 allowed for the release of psychiatric evaluation, lab reports, practitioner ' s orders, discharge summary/instructions, history/physical, practitioner ' s progress note, discharge summary/instructions, treatment/individualized service plan, medication records, financial/account information, alcohol/drug/substance abuse records, mental health records, billing and HLOC.Patient #7 was admitted on March 28, 2022 and discharged on April 21, 2022. A consent to release information to a funding source dated March 28, 2022 allowed for the release of psychiatric evaluation, lab reports, practitioner ' s orders, discharge summary/instructions, history/physical, practitioner ' s progress note, discharge summary/instructions, treatment/individualized service plan, medication records, financial/account information, alcohol/drug/substance abuse records, mental health records, billing claims, immunization record, and HLOC. A consent to release information to a government agency dated March 28, 2022 allowed for the release of discharge summary/instructions, treatment/individualized service plan, alcohol/drug/substance abuse records, other-UDS, and attendance. These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the November 5, 2021 licensing inspection.
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Plan of Correction
Pottstown CTC Clinic Director and Office Manager will ensure that all release of information forms are obtained with specific information disclosed. All releases of information will be reviewed for accuracy and that these releases of information are completed in its entirety on a monthly basis. This information was presented during the June 9, 2022 staff meeting to ensure compliance to this regulation. All current clients listed in this citation will sign new corrected releases by June 30, 2022. The CTC Director will monitor compliance in this area. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of patient records, the facility failed to submit a written unusual incident report to the Department for four unusual incidents within the required three business days. Patient #8 died on March 9, 2022. No report submitted.Patient #9 died March 21, 2022. No report submitted.Patient #10 died April 8, 2022. No report submitted.Patient #11 died March 2, 2022. No report submitted.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure timely reporting of unusual incidents, hierarchy of reporting incidents has been implemented. In the absence of Clinic Director, all staff will be trained on proper procedures for reporting unusual incidents timely. Procedure for Reporting Unusual Incidents to DDAP was reviewed during staff meeting 6/9/22. Clinic Director will ensure corrective action is implemented and compliance in this area is maintained. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of patient records, the facility failed to inform the Department of two incidents on March 21, 2022 and April 13, 2022 involving police presence at the facility. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure timely reporting of unusual incidents, hierarchy of reporting incidents has been implemented. In the absence of Clinic Director, all staff will be trained on proper procedures for reporting unusual incidents timely. Procedure for Reporting Unusual Incidents to DDAP was reviewed during staff meeting 6/9/22. Clinic Director will ensure corrective action is implemented and compliance in this area is maintained.
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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 patient records, the facility failed to provide each patient with an average of 2.5 hours of psychotherapy per month during the patient's first two years in two out of four applicable patient records. Patient #4 was admitted on January 11, 2021 and was still active at the time of the inspection. The patient received one hour of counseling in January, and 1.5 hours of counseling in February.Patient #6 was admitted on August 5, 2021 and discharged April 18, 2022. The patient received two hours of counseling in February.These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the November 15, 2019, December 30, 2020, and November 5, 2021 licensing inspections.
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Plan of Correction
Pottstown 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 June 9,2022. As of June 9, 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.
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 consideration of an Administrative Medically Supervised Withdrawal.
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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 conduct an annual physical examination in the regulatory timeframe in one out of two applicable records reviewed.Patient #4 was admitted on January 11, 2021 and was still active at the time of the inspection. An annual physical was due no later than January 11, 2022; however, it was completed on February 9, 2022. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the November 5, 2021 licensing inspection.
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Plan of Correction
Pottstown CTC Medical staff will ensure all patient records reflect annual physical examination as per regulatory guidelines. Medical staff and CTC Clinic Director will monitor monthly for compliance. |
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 complete an annual evaluation by the counselor which includes addressing the financial management abilities within the regulatory timeframe in two out of two applicable records reviewed. Patient #4 was admitted on January 11, 2021 and was still active at the time of the inspection. An annual clinical evaluation was due on or before January 11, 2022; however, it was not completed until March 23, 2022. Additionally, it did not include addressing the financial management responsibilities of the patient.Patient #5 was admitted on March 3, 2009 and was still active at the time of the inspection. An annual clinical evaluation was due on or before March 3, 2022; however, it was not completed until March 8, 2022. Additionally, it did not include addressing the financial management responsibilities of the patient.These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the November 5, 2021 licensing inspection.
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Plan of Correction
Pottstown CTC will ensure that all documentation required for patients files will be completed in a timely manner and will be reviewed by the Clinical Supervisor. 5% of patient charts will be internally audited for completion on a monthly basis.
The clinic director will meet with the Medical Director in order to review the necessity for the Medical Director to review and sign off on all clinical annual evaluations completed by the primary clinicians.
The CTC Director will monitor compliance in this area.
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709.92(a) 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:
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Observations
Based on the review of patient records, the facility failed to develop an individual treatment plan within the regulatory timeframe in two out of five 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 #2 was admitted on November 29, 2021 and was still active at the time of the inspection. There was no documentation of a comprehensive treatment plan at the time of the inspection. Patient #3 was admitted on January 31, 2022 and was still active at the time of the inspection. The comprehensive treatment plan was due March 3, 2022 and was completed on March 17, 2022.These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the November 5, 2021 licensing inspection.
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Plan of Correction
The Clinic Director met with the Clinical Supervisor to review regulation 709.92(a). A more thorough review of patient files will be conducted to ensure that counseling staff are completing necessary paperwork and documentation in a timely manner. The continued utilization of the EMR will ensure that all documentation is met within allotted time frames necessary to meet this regulation.
During the June 9, 2022 clinical staff meeting, the clinical supervisor reviewed this regulation and required that all counseling staff complete internal audits of patient electronic records on a weekly basis. The Clinical Supervisor will monitor compliance in this area.
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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 the review of patient records, the facility failed to review and update the patient's treatment plan at least every 60 days in two out of three applicable records reviewed. Patient #4 was admitted on January 11, 2021 and was still active at the time of the inspection. A treatment plan was completed on December 16, 2021 and the next one was due no later than February 16, 2022; however, it was not completed until April 8, 2022. Patient #5 was admitted on March 3, 2009 and was still active at the time of the inspection. A treatment plan was completed on December 23, 2021 and the next one was due no later than February 23, 2022; however, it was not completed until March 25, 2022. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the November 5, 2021 licensing inspection.
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Plan of Correction
The Clinic Director met with the Clinical Supervisor to review regulation 709.92(b). A more thorough review of patient files will be conducted to ensure that counseling staff are completing necessary paperwork and documentation in a timely manner. The continued utilization of the EMR will ensure that all documentation is met within allotted time frames necessary to meet this regulation.
During the June 9, 2022 clinical staff meeting, the clinical supervisor reviewed this regulation and required that all counseling staff complete internal audits of patient electronic records on a weekly basis. . The Clinical Supervisor will monitor compliance in this area.
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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 plans in three out of seven records reviewed. Patient #3 was admitted on January 31, 2022 and was still active at the time of the inspection. A treatment plan dated March 17, 2022 indicated individual 30 minute bi-weekly sessions and 1 hour of group per week. There was no individual session the week of April 5, 2022. In addition, there were zero documented group hours between March 17, 2022 through April 21, 2022.Patient #4 was admitted on January 11, 2021 and was still active at the time of the inspection. A treatment plan dated December 16, 2021 indicated monthly individual sessions. There were no individual sessions in the month of January.Patient #5 was admitted on March 3, 2009 and was still active at the time of the inspection. A treatment plan dated December 23, 2022 indicated 30-minute individual sessions and two hours of group sessions monthly. There were no individual nor group sessions in the month of February.These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the November 5, 2021 licensing inspection.
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Plan of Correction
It remains essential to ensure patients are adhering to the clinical parameters jointly established between them and their primary counselor.
During regularly scheduled supervision, the counselor will review with the clinical supervisor random treatment plans and gauge patient compliance to such, developing plans to ensure patient compliance to same.
A summary review of the various plans that may be uniquely devised for each patient, during individual supervision, will be shared with the counseling team during monthly group supervision sessions to aid in offering additional creative ways to address patient non-compliance.
Utilizing reports from SMART, review of patient expected clinical engagement will also be reviewed to ensure there is cohesiveness between patients expected level of service need(s) and what is reported on the patient individual treatment plan.
Certainly, amidst the current Pandemic (sars-cov-2) the use of telehealth services will aid in achieving compliance to 709.92(b).
This plan was reviewed with the Clinical Supervisor on July 1, 2022 and rolled out to the counseling team that same day; with a review offered during the July 15, 2022 monthly staff meeting.
The Clinical Supervisor will monitor compliance in this area.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of patient records, the facility failed to document case consultations within the regulatory timeframe in three out of six applicable patient records. The facility's policy and procedures manual, section 7.3.2 states "all patients will have their treatment reviewed at a minimum, quarterly for the first year and annually thereafter". Patient #2 was admitted on November 29, 2021 and was still active at the time of the inspection. A case consultation was due no later than March 1, 2022 and was not completed until March 23, 2022.Patient #4 was admitted on January 11, 2021 and was still active at the time of the inspection. A case consultation was due no later than January 11, 2022 and was not completed until March 23, 2022.Patient #5 was admitted on March 3, 2009 and was still active at the time of the inspection. A case consultation was due no later than March 3, 2022 and was not completed until March 8, 2022.These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the November 5, 2021 licensing inspection.
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Plan of Correction
Plan of Correction:
The Clinical Supervisor will continue to conduct weekly and monthly reviews of all services necessary, including that of Case Consultation notes due. The review of this regulation was addressed during clinical staff meeting on June 9, 2022. As of June 9, 2022, each counselor will run their Direct Services Analysis reports in the EMR Case Consults will be documented within the EMR in order to meet this regulation. . The Clinical Supervisor will monitor compliance in this area.
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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 patients to receive an average of 2.5 hours of psychotherapy per month during the patient's first two years were submitted and approved by the Department for the November 15, 2019, December 30, 2020, and November 5, 2021 annual licensing inspections. This is a repeat citation from the November 5, 2021 licensing inspection. These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Pottstown 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.
Counseling Requirements: If a patient does not meet the minimum counseling requirement during the month, the reason for such will be documented in the patient file. Counselors will continue to attempt to contact patients who are not meeting the minimum monthly counseling requirement immediately following a missed appointment, or after 4 weeks have passed without a clinical session. Patients who continue to refuse to meet minimum counseling requirements are placed on a Treatment Contract. A treatment team meeting is be held to review therapeutic interventions and strategies to increase session attendance. Approved interventions are incorporated into a Treatment Contract that is presented to and signed by the patient. CTC staff will determine, when a non-compliant patient may be eligible for Administrative Discharge due to counseling non-compliance. This decision will be made at a treatment team meeting, with agreement of the CTC physician, and the patient must be placed on an appropriate administrative detoxification schedule.
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