INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 29-31, 2013 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:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the facility's staffing requirements facility summary report (SRFSR), the facility failed to ensure that staff persons and/or volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum as per the regulatory requirements in three of eight records reviewed.
The findings include:
The facility's SRFSR form completed by the facility on October 30, 2013 was reviewed on October 30, 2013. The form listed three staff as not having completed the mandatory training within the regulatory time frames
Employee # 5, a counselor, was hired on September 10, 2012. Employee # 5 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by September 10, 2013. The trainings were not completed until October 16, 2013 and October 23, 2013 respectively.
Employee # 6, a counselor, was hired on August 20, 2012. Employee # 6 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by August 20, 2013. The trainings were not completed until October 16, 2013 and October 23, 2013 respectively.
Employee # 8, a counselor, was hired on August 13, 2012. Employee # 6 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by August 13, 2013. The 4 hours of TB/STD training was not completed.
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Plan of Correction
All staff have the required Communicable Disease Training, with the exception of one counselor, who is registered to attend HIV on 1/15/14. Two others in need of these trainings are within the regulatory timeframe of obtaining such.
Newly hired staff will be required to have all mandatory trainings written into their individual training plans and complete within the mandatory time allowed.
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of administrative documentation and discussion with facility staff, the facility failed to maintain counselor caseloads to no more than 35 to 1.
The findings include:
Administrative documentation that included counselor caseloads was reviewed and discussed with facility staff on October 29, 2013. The administrative staff acknowledged that they required another counselor to meet facility needs, and in fact had recently hired a new counselor that would be starting in the near future.
Staff # 4 had a caseload of 39 to 1 according to administrative documentation reviewed on October 29, 2013.
Staff # 5 had a caseload of 37 to 1 according to administrative documentation reviewed on October 29, 2013.
Staff # 7 had a caseload of 38 to 1 according to administrative documentation reviewed on October 29, 2013.
Staff # 8 had a caseload of 36 to 1 according to administrative documentation reviewed on October 29, 2013.
Staff # 9 had a caseload of 37 to 1 according to administrative documentation reviewed on October 29, 2013.
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Plan of Correction
Currently this facility is fully staffed with 7 counselors to meet our census capacity of 245. Admissions were suspended to prevent further compliance issues. Proactive measures will be taken in the form of interviewing for potential employees to help protect against ratio issues due to staffing changes in the future. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ensure the facility bathrooms were ventilated as required.
The findings include:
A physical plant inspection was conducted October 31, 2013. There was no ventilation in any of the facility bathrooms. There were no windows and the vents did not have any movement which was verified by facility staff.
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Plan of Correction
This facility has sought out a general contractor to address the ventilation issue in the bathrooms. Bathroom exhaust fans will be operating properly by January 8, 2014. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of patient records, the facility failed to maintain the confidentiality of patient information in two of eight patient records reviewed.
The findings include:
Sixteen patient records were reviewed October 29-31, 2013. Eight patient records were reviewed specifically for confidentiality compliance.
Patient # 13 was transferred to another narcotic treatment facility April 1, 2013. Information was released to the receiving facility without benefit of a signed written consent to release information.
Patient # 16 was admitted to the facility June 3, 2013. The patient was AWOL and it was learned the patient was in a behavioral hospital from July 26, 2013, who contacted the facility for information. Information was released without benefit of a signed consent to release information.
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Plan of Correction
Confidentiality will be reviewed and documented in the form of staff training for the upcoming calendar year. All staff will be required to review release forms on a quarterly basis for on-going changes. Staff will ensure proper consent forms are in place before releasing any information to any outside parties. |