INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on Oct. 13, 2011, 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project director in one of one personnel records.
The findings include:
Seven personnel records were reviewed on October 11, 2008. One personnel record pertained to the project director. One personnel record required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 has been the project director since October 14, 2011. The facility training year is from July 1, 2010 through June 30, 2011. Employee # 1 failed to have 12 clock hours of annual training documented.
A discussion with the facility director occurred on October 11, 2011 and confirmed the lack of training hours for the 2010-2011 training year.
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Plan of Correction
The Program Director reviewed the training requirement with the Project Director on October 14, 2011. The Program Director will contact the Project Director at the end of each quarter to obtain information regarding any training hours obtained during that quarter and to remind the Project Director of the need to obtain the training hours as required. This will ensure that by the end of the third quarter, the Project Director will have had time to scheduleany further training hours needed. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill logs the facility failed to conduct unannounced fire drills at least once per month as required by regulation.
The findings include:
The fire drill logs were reviewed on October 13, 2011. There was no documentation of unannounced fire drills for the month of July 2011.
An interview took place with the facility director on October 13, 2011. It was confirmed that a fire drill was not conducted during that month.
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Plan of Correction
The Program Director has developed a tickler system to ensure that the monthly fire drills are conducted. This includes randomly assigning a date and time for a fire drill each month, entered on the Program Director's personal calendar. It also includes a log which is prepared each month in advance and includes a reminder of the need to ensure that the drill is conducted and the relevant report is written. The Administrative Assistant will then verify, during the last two days of each month, that the drill has been conducted. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the annual report, the facility failed to make the annual report available to the public.
The findings include:
The annual report for the 2010 year was reviewed on October 11, 2011. The annual report was not made available to the public.
This was discussed with and confirmed by the director on October 11, 2011 at 12:22 p.m.
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Plan of Correction
The Program Director reviewed the regulation with the Executive Director of Operations for Habit OPCO. The Executive Director of Operations will assume responsibility for ensuring that the Annual Report is posted on the Habit OPCO website. This posting shall take place within 30 days following the review and approval of the Annual Report by the Board of Directors. The Program Director shall verify t hat the information was posted as scheduled. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the annual report, the facility failed to include a financial statement of income and expenses in the annual report.
The findings include:
The annual report for the 2010 year was reviewed on October 11, 2011. The annual report failed to include a financial statement of income and expenses. .
This was discussed with and confirmed by the director on October 11, 2011 at 12:22 p.m.
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Plan of Correction
The Program Director reviewed the regulation with the Executive Director of Operations for Habit OPCO. This report will include a statement of income and expenses as required. The Program Director and the Executive Director of Operations will review the Annual Report to ensure compliance with the regulation. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of the client records, the facility failed to document a personal history that included detail in the areas of family history, legal history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history and sexual history in two of four records.
The findings Include:
Nine records were reviewed October 13, 2011. Six records were reviewed for compliance with the regulations. Two records did not document personal histories that included all components of a personal history that are comprised of family history, legal history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history, and sexual history. Specifically, patient records # 3 and 9. Per facility policy, personal histories will be completed within thirty days of the patient's admission to the program.
Record #3 - Patient was admitted on 5-09-2011. The personal history failed to include detail in the areas of family history, legal history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history, and sexual history. This patient was a previous patient at the clinic. The facility failed to update the client's personal history. They used a history that was over six months old.
Record #9 - Patient was admitted on 4-14-2011. The personal history to include family history, legal history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history, and sexual history was due by 5-14-2011. The facility documented a personal history on 5-25-2011. The personal history on this patient was eleven days late.
The facility director confirmed this finding.
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Plan of Correction
The Program Director reviewed the relevant regulations and deficiencies at the general staff meeting on November 1, 2011. The process of completing the intake and biopsychosocial history has been changed so that the counselors are now completing the biopsychosocial history prior to the patient being formally admitted to the program. The Clinical Director will review the documentation for all new admissions, including readmissions, on an ongoing basis, to ensure that the regulations are being followed. This regulation will also be reviewed by the Clinical Director in group supervision and individual supervision by December 1, 2011. Ongoing chart reviews will also address this requirement. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of patient records and the facility's policy and procedures, the facility failed to document a psychosocial evaluation in one of four patient records. Additionally, one of four patient records contained psychosocial evaluations that were not completed within the required timeframe.
The findings include:
The facility's policy and procedures were reviewed on October 11, 2011. Per the facility's policy and procedures, a psychosocial evaluation will be completed within thirty days of admission. Nine patient records were reviewed on October 13, 2011. Four of the patient records were reviewed to have a psychosocial evaluation. The facility failed to document a psychosocial evaluation in patient record # 3. The facility documented a late psychosocial evaluation in patient record # 9.
Patient # 3 was admitted on May 9, 2011. The psychosocial evaluation was due by June 8, 2011. The facility failed to document a psychosocial evaluation in the patient record as of the date of the inspection.
Patient # 9 was admitted on April 14, 2011. The psychosocial evaluation was due by May 14, 2011. The psychosocial evaluation was documented on May 25, 2011. This was documented eleven days late.
Patient # 9 was admitted on August 5, 2011. The psychosocial evaluation was due by September 3, 2011. The facility failed to document the completion of a psychosocial evaluation as of October 12, 2011.
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Plan of Correction
The Clinical Director will review the regulations with the clinical staff at the next group supervision meeting in November. The Clinical Director will ensure that the report of all psychosocial evaluations due is run via the treatment management software (SMART) each Tuesday. Any psychosocial evaluations that are due within the coming five working days will be noted and the assigned counselor will be advised that the completed psychosocial evaluation must be done and signed within three working days. The Program Director will review the same report in SMART monthly for three months to ensure that this process is being followed. |
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 and the facility's policy and procedures, the facility failed to document a treatment and rehabilitation plan within the required time frame.
The findings include:
Nine patient records were reviewed on October 13, 2011. Per the facility's policy and procedures, an individual treatment and rehabilitation plan shall be developed within thirty days of admission. Four patient records were reviewed for initial individual treatment and rehabilitation plans. The facility failed to document an individual treatment and rehabilitation plan within thirty days in three of four records, specifically # 2, 3, and 9.
Patient # 2 was admitted June 3, 2011. The initial individual treatment and rehabilitation plan was due by July 3, 2011. The facility documented the individual treatment and rehabilitation plan on September 24, 2011. This was over two months late.
Patient # 3 was admitted on May 9, 2011. The initial individual treatment and rehabilitation plan was due by June 8, 2011. The facility documented the individual treatment and rehabilitation plan on August 18, 2011. The individual treatment plan was not only over a month late, it was also developed prior to documenting a personal history.
Patient # 9 was admitted on April 14, 2011. The initial individual treatment and rehabilitation plan was due by May 14, 2011. The facility documented the individual treatment and rehabilitation plan on July 20, 2011. This was over two months late.
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Plan of Correction
The Clinical Director will review the regulations with the clinical staff at the next group supervision meeting in November. The Clinical Director will ensure that the report of all initial treatment plans due is run via the treatment management software (SMART) each Tuesday. Any initial treatment plans that are due within the coming ten working days will be noted and the assigned counselor will be advised that the completed initial treatment plan must be done and signed within five working days. The Program Director will review the same report in SMART monthly for three months to ensure that this process is being followed. |
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 patient records and a review of the facility's policy and procedures, the facility failed to document a treatment and rehabilitation plan update at least every 60 days in four of five records.
The findings include:
Nine patient records were reviewed on October 13, 2011. Five records were reviewed for updated treatment and rehabilitation plans. Per the facility's policy and procedures, treatment plans will be updated every 60 days. The facility failed to document treatment plan updates within the required time frame in patient records # 6, 7, 8, and 9.
Patient # 6 was admitted on July 16, 2009 and discharged on April 5, 2011. The patient had a treatment plan update documented on October 26, 2010. The next treatment plan update was due December 26, 2011. The facility documented the next treatment plan update on January 12, 2011. The treatment plan update was 17 days late. The next treatment plan update was due on March 12, 2011. The facility failed to document this treatment plan prior to the patient being discharged.
Patient # 7 was admitted on January 7, 2010 and discharged on March 24, 2011. The patient had a treatment plan update documented on December 7, 2010. The next treatment plan was due on February 7, 2011. The facility documented the treatment plan update on February 24, 2011. The treatment plan update was 17 days late.
Patient # 8 was admitted on June 8, 2010 and discharged on April 12, 2011. The patient had a treatment plan update documented on January 13, 2011. The next treatment plan update was due March 13, 2011. The facility failed to document this treatment plan prior to the client being discharged. Review of the record revealed that the treatment plan completed on January 13, 2011 was not signed by the patient and the record did not indicate that the treatment plan was reviewed with the patient. The treatment plan update had "Patient Not Available to Sign" and was dated April 14, 2011 which was after the patient was discharged.
Patient # 9 was admitted on April 14, 2011. The patient had a treatment plan documented on June 20, 2011. The treatment plan update was due August 20, 2011. The facility failed to document a treatment plan update in this patient record as of the date of the inspection.
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Plan of Correction
The Clinical Director will review the regulations with the clinical staff at the next group supervision meeting in November. The Clinical Director will ensure that the report of all treatment plan updates due is run via the treatment management software (SMART) each Tuesday. Any treatment plan updates that are due within the coming ten working days will be noted and the assigned counselor will be advised that the completed treatment plan update must be done and signed within five working days. The Program Director will review the same report in SMART monthly for three months to ensure that this process is being followed. |
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 and the facility's policy and procedure, the facility failed to document a case consultation in two of eight records reviewed. Additionally, two of eight records reviewed had a case consultation that was not documented within the facility's required time frame.
The findings include:
Nine patient records were reviewed on October 13, 2011. Eight patient records required a case consultation. Per facility policy and procedures, case consultations will be documented at least quarterly for the first year and annually thereafter. The facility failed to document case consultations in client records # 2 and 3. Also, the case consultations documented in client records # 1 and 9 were not completed in the required time frame.
Patient # 1 was admitted on May 31, 2011. A case consultation was due by August 31, 2011. The facility documented the case consultation on September 14, 2011. This was 14 days late.
Patient # 2 was admitted on June 23, 2011. A case consultation was due by September 23, 2011. The facility failed to document a case consultation in this patient record as of the date of the inspection.
Patient # 3 was admitted on May 9, 2011. A case consultation was due by August 9, 2011. The facility failed to document a case consultation in this patient record as of the date of the inspection.
Patient # 9 was admitted on April 14, 2011. A case consultation was due by July 14, 2011. The facility documented a case consultation on September 23, 2011. This was over two months late.
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Plan of Correction
The Clinical Director will review the regulations with the clinical staff at the next group supervision meeting in November. The Clinical Director will ensure that the report of all case consultations due is run via the treatment management software (SMART) each Tuesday. Any case consultations that are due within the coming ten working days will be noted and the assigned counselor will be advised that the completed case consultation must be done and signed within five working days. The Program Director will review the same report in SMART monthly for three months to ensure that this process is being followed. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of patient records, the facility failed to document an aftercare plan in one of one record.
The findings include:
Nine patient records were reviewed on October 13, 2011. Five discharged patient records were reviewed. One patient successfully completed the program and required an aftercare plan. Per the facility's policy and procedures, at least one week prior to the patient completing treatment, the facility will complete an aftercare for patients who successfully complete treatment.
Patient # 6 was admitted to the program on July 16, 2009. This patient successfully completed the program on April 5, 2011. The facility failed to document an aftercare plan in this patient record.
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Plan of Correction
This regulation was reviewed at the general staff meeting on November 1, 2011. The Clinical Director will review the regulations with the clinical staff at the next group supervision meeting in November as well. The Clinical Director will ensure that any patients who are on a voluntary methadone withdrawal and whose dose is less than 20 milligrams is scheduled to meet with the primary counselor to complete the aftercare plan. The counselor will utilize a "hard hold" on the day of the aftercare planning appointment to ensure that the patient is seen and the aftercare plan is developed. If the patient refuses to comply with the process, the counselor will note this in the patient's chart. The Clinical Director or designee will identify and discuss any patients on a voluntary methadone withdrawal in individual supervision meetings to ensure that the counselor is aware of the need to comply with this process. The multi-diciplinary team will also identify these patients at the weekly team meeting. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document a discharge summary within one week of discharge in two of five patient records.
The findings include:
Nine patient records were reviewed on October 13, 2011. Per agency policy, discharge summaries are due within one week of discharge. Discharge summaries were required in five patient records. The facility failed to document a discharge summary within one week of discharge in patient records # 6 and 8.
Client # 6 was admitted on July 16, 2009 and was discharged on April 5, 2011. The discharge summary was due by April 12, 2011 The discharge summary was completed on May 5, 2011.
Client # 8 was admitted on June 8, 201 and was discharged on April 12, 2011. The discharge summary was due by April 19, 2011 The discharge summary was completed on May 12, 2011.
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Plan of Correction
The Program Director reviewed the regulations and Habit OPCO policies regarding discharge summaries at the general staff meeting on November 2, 2011. The Clinical Director will ensure that the report of all discharge summaries due is run via the treatment management software (SMART) each Monday. Any discharge summaries that are due within the coming week will be noted and the assigned counselor will be advised that the completed discharge summary must be done and signed within five working days, and the paper document must be handed in for signature to the Clinical Director. The Clinical Director will maintain a log of discharges and accompanying discharge summaries to ensure compliance with this plan. The Program Director will review the same report in SMART monthly for three months to ensure that this process is being followed. |