INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 20-21, 2017 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 to be not 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
|
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
|
Observations
Employee #8 was hired as bachelor's level counselor assistant on 4/17/17. A supervision log, which contains a column to denote when direct observation occurs, indicated that supervision was provided on a weekly basis from 5/2/17 through 11/20/17, however 1 hour of direct observation was only documented during the following weeks: 5/22-26/17, 6/5-9/17, 7/10-14/17, 7/17/21/17, 7/24/28/17, 8/7/-11/17, 8/21-25/17, 8/28-9/1/17, 9/4-8/17, 9/18-22/17 and 9/25-29/17. #8 was out on medical leave from 9/29/17 through 11/20/17, therefore no supervision was conducted during that timeframe.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
Current Counselor Assistant was promoted to Counselor as of 11/27/17, thus negating the need for continued direct observation. Clinical Supervisor will provide ongoing supervision as scheduled. Should a Counselor Assistant be hired in the future,supervision will be conducted by the Clinical Supervisor in accordance with the educational level of said CA. All supervision will be documented accordingly by the Clinical Supervisor. This will be monitored monthly by the Facility Director. |
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.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report conducted on November 20, 2017, the facility failed to ensure that employees #3, 6 & 9 did not exceed 35 active clients.
Employee #3 works 22.5 hours and has 31 clients yielding a ratio of 49:1.
Employee #6 works 37.5 hours and has 43 clients yielding a ratio of 42:1.
Employee #9 works 34.5 hours and has 35 clients yielding a ratio of 36:1.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
As of 12/14/17, Facility Director is currently in the process of recruiting and hiring staff to correct the issue of ratio compliance. Staff returning from FMLA on 1/2/18, which will further enable the maintenance of ratio compliance. The Clinical Supervisor will monitor ratio weekly, when assigning new admissions to counselors. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
Facility policy and procedure manual was reviewed on November 20, 2017. The facility policy failed to include the following elements with regard to client rights:
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 12/4/17, the Project policy regarding Client Rights, and related documents, was revised to include the following:
To inspect their own records, in the presence of the CTC Director/designee. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
a. Clients have the right to appeal a decision limiting access to their records to the director.
b. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
c. Clients have the right to submit rebuttal data or memoranda to their own records.
The policy and procedure manual for the facility has been updated accordingly.
In addition, the client rights form has been updated. All patients will have the revised client rights form presented and signed by 1/31/18. This will be reviewed by the Facility Director to ensure completion at that time. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
|
Observations
Based on a review of administraive paperwork and a review of the physician's schedule on November 20, 2017, the facility failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.
A schedule was submitted that indicated the hours worked for the physician and the physician extender staff, as well as the patient census, for the weeks from June 5, 2017 through October 10, 2017. The facility was not in compliance for the following weeks:
June 5-11, 2017: census 266, requiring 26.6 hours. Actual coverage: 24 hours.
June 12-18, 2017: census 267, requiring 26.7 hours. Actual coverage: 24 hours.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
As of 12/5/17, the Facility Director and Assistant Director will monitor census weekly via EMR reports to ensure doctor hours are sufficient for the current number of patients. Coverage will be provided for when the physician and the physician extender is unable to fulfill their contracted hours in a given week. |
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.
|
Observations
Seven client records were reviewed on November 21, 2017, four of which were methadone client records. The facility failed to conduct an annual physical annually in client records #3 & 4.
Client #3 was admitted on 7/10/14 and was an active client at the time of the licensing inspection.
An annual physical examination was conducted on 7/24/16; another annual physical was due to be conducted by 7/24/17 but was not documented until 9/18/17.
Client #4 was admitted on 12/8/15 and was discharged on 2/10/17.
An initial physical examination was conducted on 12/8/15; an annual physical was due to be conducted by 12/8/16 but was not documented until 1/8/17.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
As of 12/5/17, the Nurse Manager will place a scheduling hold for each patient due for an annual physical, two weeks prior to the due date. Appointments will be scheduled by the nurses. The MD/CRNP will document any "no show" appointments accordingly and notify nursing to indicate the need for a reschedule. The Nurse Manager will monitor all Annual Physical appointments weekly. |
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.
|
Observations
Seven client records were reviewed on November 21, 2017, four of which were methadone client records; the facility failed to update the treatment plan in client records, #1 and 3.
Client #1 was admitted on 7/17/15 and was an active client at the time of the licensing inspection.
A treatment plan update was documented on 5/22/17; a treatment plan update was due by 7/22/17, but was not documented until 9/13/17.
Client #3 was admitted on 7/10/14 and was an active client at the time of the licensing inspection.
A treatment plan update was documented on 5/17/17; a treatment plan update was due by 7/17/17, but was not documented until 8/16/17. Additionally, a treatment plan update was documented on 9/15/17; a treatment plan update was due by 11/15/17, but was not documented until 11/17/17.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
As of 12/5/17, all Counselors will print the services due report weekly. Treatment plan updates will be completed every 60 days and monitored via this report. Appointments to review updated treatment plan goals/objectives or to complete a treatment plan with the patient will be scheduled accordingly by Counselors. Appointments not kept by patients will be documented in the EMR under "no show treatment plan appointment." Services due reports will be reviewed in supervision with the Clinical Supervisor to ensure timeliness of documentation. |