INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the October 13, 2011 licensure renewal inspection. The follow-up inspection was conducted on May 30, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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, 2011. 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 facility 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.
This was still out of compliance at the time of the follow-up conducted on May 30, 2012.
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Plan of Correction
The Program Director reviewed the training requirement with the PA Director of Operations during the site visit on May 30, 2012.
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 schedule any further training hours needed.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs, the facility failed to activate a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill logs were reviewed on May 30, 2012. Per regulation, the nonresidential facility shall set off a fire alarm or smoke detector during each fire drill. The fire drill log was reviewed for documentation of fire drills for the time period of October 2011 to April 2012. The facility documented that the alarms were operative, however, during an interview with the facility director it was disclosed that they were not setting off a fire alarm or smoke detector during each fire drill. The facility director indicated they were sounding an alternative device to evacuate the building and not sounding the fire alarm or smoke detector.
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Plan of Correction
The Program Director will re-draft the fire drill procedures on site to include specific directions as to the use of the on site smoke detection units during each Monthly Fire Drill. This information was presented and reviewed with staff on Thursday, June 7, 2012 and will be presented and reviewed again with all staff at the monthly schedule staff meetings in July. The Program Director will ensure that all subsequent Monthly fire drills on site occur with the annunciation of the smoke detectors as described in the re-drafted fire drill procedures; beginning with a drill on June 27, 2012. During all fire drills, all smoke detectors on site will be tested for annunciation; the results will be documented accordingly in the fire drill notations. The procedures put into place on June 27, 2012 will be reviewed every month henceforth and discussed during the monthly staff meetings in July and again in August 2012 to ensure their effectiveness. Additionally, these procedures will be reviewed during regular scheduled safety committee meetings to ensure compliance by all. |
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 one of eight records.
The findings Include:
Nine records were reviewed May 30, 2011. Four records were reviewed for compliance with the regulations. One record 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 record # 3.
Patient # 3 was readmitted on March 2, 2012. The facility staff 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 the patient record. The facility used a personal history dated September 28, 2010.
This finding was discussed with the facility director and Director of Pennsylvania Operations and was not disputed.
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Plan of Correction
The Program/Clinical Director will ensure the personal history for each admission/intake is recorded accordingly and that each includes documented detail in all areas of: family, legal, employment/vocational, education, military and recreational history, prior treatment experiences, patients perception of drug use, family drug abuse history and sexual history.
A thorough review of policy/procedure 709.91 will occur again during clinical group supervision on July 9, 2012. A review of this matter was presented during group supervision on Thursday, June 7, 2012.
Additionally, the deficiencies noted herein will also be discussed. Chart audits will pay close attention to compliance to this policy and expectation. Any further deficiencies noted in this area will be documented and noted. During scheduled weekly individual clinical supervision sessions, post July 9, 2012 staff will be presented with the noted deficiency along with the necessary corrections to be made and the time frame by which said corrections need to be completed.
The Program/Clinical Director will review policy/procedure 709.91 during group supervision session on August 13, 2012 to provide a review of the past months progress/corrections being made to the gathering of the necessary data; with the expectation that this matter is resolved. Should there be any outstanding issues with clinical staff related to this matter, progressive disciplinary action will be taken utilizing Action Plans for staff and the apporpriate level of action being taken. |
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 May 30, 2012. 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 four of four records, specifically # 1, 2, 3, and 9.
Patient # 1 was admitted January 20, 2012. The initial individual treatment and rehabilitation plan was due by February 20, 2012. The facility documented the individual treatment and rehabilitation plan on March 2, 2012. This documentation was eleven days late.
Patient # 2 was admitted January 30, 2012. The initial individual treatment and rehabilitation plan was due by March 1, 2012. The facility documented the individual treatment and rehabilitation plan on March 6, 2011. This documentation was five days late.
Patient # 3 was admitted on March 2, 2012. The initial individual treatment and rehabilitation plan was due by April 2, 2012. The facility documented the individual treatment and rehabilitation plan on April 7, 2012. This documentation was five days late.
Patient # 9 was admitted on October 17, 2011 and discharged on March 23, 2012. The initial individual treatment and rehabilitation plan was due by November 17, 2011. The facility documented the individual treatment and rehabilitation plan on March 1, 2012. This was over three months late. The treatment plan was not signed by the patient. This patient was not presented a treatment plan during their treatment experience with the facility.
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Plan of Correction
The Program/Clinical Director reviewed the findings of policy 709.92 with the clinical team during group supervision session on Thursday, June 7, 2012. An additional review will occur on a monthly basis during weekly group supervison. Chart reviews will be conducted by the Clinical Director, Senior Clinician, along with peer chart reviews. The results of any further deficiencies in this area will be documented accordinlgy. A follow will be conducted on July 9, 2012.
Any such deficiencies will be noted during individual supervision sessions conducted by the Clinical Director/Senior Clinician with timely compliance and corrections to be made by the clinician in question noted.
A continued review of this policy along with the monitoring of compliance to the timely completion and submission of patient initial treatment plans will be enforced and recorded during chart reviews and subsequent/on-going supervision sessions.
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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 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 one of five records.
The findings include:
Nine patient records were reviewed on May 30, 2012. 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 record # 2.
Patient # 2 was admitted on January 30, 2012. The patient had a treatment plan documented on March 6, 2012. The treatment plan update was due May 6, 2012. The counselor created a treatment plan update on May 8, 2012. Review of the record of service and documented progress notes showed that the patient had individual sessions on May 11, 2012 and May 25, 2012. There was no documentation in the patient record that indicated the treatment plan had been reviewed with the patient as of the date of the inspection. The patient had not signed off on the treatment plan and the progress notes did not indicate that the plan had been reviewed with the patient.
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Plan of Correction
A review of this deficiency and the policy was conducted on Thursday, June 7, 2012 during group supervision with the clinical team. Another review will be conducted during group supervision on Monday, July 9, 2012.
The Program/Clinical Director will ensure that updated treatment planning is completed and reviewed with each patient within a 60 day time.
Completion of chart reviews will be conducted by the clinical director, senior clinician and peer reviews. Documentation will be maintained as to compliance with this policy.
Hereto, reviews of Policy 709.92(b) will remain ongoing and be conducted during individual and group supervisory sessions. Any further deficiencies will be addressed via Clinical Action Plans being administered to clinical staff accordingly; following progressive and appropriate measures of discipline. |
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 within the facility's required time frame in two of two records reviewed.
The findings include:
Nine patient records were reviewed on May 30, 2012. Five 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 # 2 and 9 were not completed in the required time frame.
Patient # 2 was admitted on January 30, 2012. A case consultation was due by April 30, 201. The facility documented the case consultation on May 8, 2012. This was 8 days late.
Patient # 9 was admitted on October 17, 2011 and discharged On March 23, 2012. A case consultation was due by January 17, 2012. The facility failed to document a case consultation in this patient record.
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Plan of Correction
The Program/Clinical Director will ensure that case consultations are completed within the required time frame as noted in policy 709.93(a)(8).
During individual supervision sessions, case consultations will be completed related to identifying those patients targeted for the next case consultation due within the next month.
The clinical director, senior clinician and scheduled peer chart audits will review this matter and ensure compliance is maintained to the timeliness of this policy.
Completion of chart reviews will document compliance.
Reviews of Policy 709.93(a)(8) will remain ongoing and be conducted during individual and group supervisory sessions and duly noted in the notations related to the same.
Hereto, any further deficiencies to this policy will be addressed via clinical action plans with specific time frames for compliance and progressive and appropriate levels of discipline being administered. |
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 one of four patient records.
The findings include:
Nine patient records were reviewed on May 30, 2012. 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 record # 9.
Client # 9 was admitted on October 17, 2011 and was discharged on March 23, 2012. The discharge summary was due by March 30, 2012. The facility failed to document a discharge summary in this patient record as of the date of the inspection.
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Plan of Correction
The Program/Clinical Director will ensure that discharge summaries are completed within the required time frame as noted in policy 709.93(a)(10).
Deficiencies noted herein were reviewed with the clinical team on Thursday, June 7, 2012 during group supervision. During on-going weekly group supervision all cases scheduled for discharge will be discussed and reviewed to ensure discharge summaries are completed according to policy. A follow up review will be conducted on July 9, 2012 to ensure compliance to this policy.
The clinical director, senior clinician and peer chart reviews will be conducted to ensure compliance to Policy 709.93(a)(10) and will document the same.
This practice will remain ongoing as part of regular group supervision sessions. |