INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on Oct. 11, 2011 through Oct. 12, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc. - Allentown, 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.
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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 as required. This will ensure that by the end of the third quarter, the Project Director will have time to schedule any further training hours needed. |
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 report will include a statement of income and expenses as required. 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 that 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 shall verify that the information was included as per regulation. |
709.28(c) 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 shall be in writing and include, but not be limited to:
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Observations
Based on a review of patient records, the facility failed to obtain an informed and voluntary consent from the patient prior to the disclosure of information in one of nine records reviewed. Additionally, the facility released specific patient information that exceeded the limits imposed by 4 Pa. Code 255.5 in two of nine records reviewed.
The findings include:
Nine patient records were reviewed on October 12, 2011. All patient records were required to include an informed and voluntary consent from the client prior to the disclosure of information. One record, # 7 documented a verification letter was faxed, but there was no documentation of a consent form signed by the clients for the clinic that the information was being released.
Patient # 1 was admitted on 7-16-09. A release in the patient record to the insurance company exceeded 4 Pa. Code 255.5. The release allowed for the release of the patient's methadone dose. There was documentation in the patient record that the dose was released to the insurance company on 10/22/2010, 1/13/2011, and 5/17/2011.
Patient # 4 was admitted on March 23, 2011. A release int he patient record to the insurance company exceeded 4 Pa. Code 255.5. The release allowed for the release of the patient's methadone dose, discharge summary, psychosocial evaluation, prescription verification, medical evaluation, HIV/AIDS information, and lab work results.
A discussion with the facility director occurred on October 12, 2011 at 9:30 a.m. and confirmed this finding.
This is a repeat citation from the October 6, 2010 and October 7, 2009 licensing inspections.
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Plan of Correction
The Program Director reviewed the regulations and related deficiencies in detail at the staff meeting on November 3, 2011. The entire staff was informed that for the next four months, no information is to be released without prior supervisory approval. In addition, all staff members who have not attended the Department of Health training on confidentiality will be required to do so within the coming twelve months. Also, the front desk staff, who have the day to day task of obtaining patient signatures on Consents to Release Information, have been instructed not to proceed with obtaining signatures for any Consent that has more than the following information to be released: a.) length of treatment; b.) treatment modality; c.) presence in treatment, until having obtained supervisory approval. |
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 six records.
The findings Include:
Nine records were reviewed October 12, 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 # 8 and 9.
Record #8 - 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 8-05-2011. The personal history failed 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. This patient was a previous patient at the clinic. The facility failed to update the client's personal history which was over six months old.
The facility director confirmed this finding.
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Plan of Correction
On November 2, 2011, the Program Director reviewed the regulations at the general staff meeting, including the regulations regarding readmissions. 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. 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 it will be reviewed in individual supervision as well, by December 1, 2011. |
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 six patient records. Additionally, two of six 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 12, 2011. Six of the patient records were reviewed to assess the psychosocial evaluation. The facility documented late psychosocial evaluations in patient records # 4 and 8. The facility failed to document a psychosocial evaluation in patient record # 9.
Patient # 4 was admitted on March 23, 2011. The psychosocial evaluation was due by April 22, 2011. The psychosocial evaluation was documented on May 3, 2011. This was eleven days late.
Patient # 8 was admitted on May 9, 2011. The psychosocial evaluation was due by June 7, 2011. The psychosocial evaluation was documented on July 1, 2011. This was twenty-five 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 ensure that the report of all psychosocial evaluations due is run via the treatment management software (SMART) each Monday. Any psychosocial evaluations that are due within that week will be noted and the assigned counselor will be advised that the completed psychosocial evaluation must be done and signed within three 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 ensure that an individual treatment and rehabilitation plan was developed within the required timeframe.
The findings include:
Per the facility's policy and procedures, an individual treatment and rehabilitation plan shall be developed within thirty days of admission. Nine patient records were reviewed on October 12, 2011. Six patient records were reviewed for the initial treatment and rehabilitation plan. The facility failed to document an initial treatment and rehabilitation plan within thirty days in four of six records reviewed, specifically records # 4, 7, 8, and 9.
Patient # 4 was admitted on March 23, 2011. An individual treatment and rehabilitation plan was due by April 22, 2011. The individual treatment and rehabilitation plan was completed on May 3, 2011. This was ten days late.
Patient # 7 was admitted on September 8, 2011. An individual treatment and rehabilitation plan was due by October 7, 2011. The facility had not documented an individual treatment and rehabilitation plan in this record as of the date of the inspection.
Patient # 8 was admitted on May 9, 2011. An individual treatment and rehabilitation plan was due by June 8, 2011. The facility documented an initial treatment and rehabilitation plan on July 25, 2011. This was forty-seven days late.
Patient # 9 was admitted on August 5, 2011. An individual treatment and rehabilitation plan was due by September 4, 2011. The facility failed to document an initial treatment and rehabilitation plan as of the date of the inspection.
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Plan of Correction
The Program Director reviewed the regulations and Habit OPCO policies regarding the initial treatment plan at the general staff meeting on November 2, 2011. The Clinical Director will ensure that the report of all initial treatment plans due is run via the treatment management software (SMART) each Monday. Any initial treatment plans that are due within the coming two weeks 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 seven records.
The findings include:
Nine patient records were reviewed on October 12, 2011. Seven 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 timeframe in patient records # 1, 2, 3 and 8.
Patient # 1 was admitted on July 16, 2009. The patient had a treatment plan update documented on February 23, 2011. The next treatment plan update was due April 23, 2011. The facility documented the next treatment plan update on May 3, 2011. The treatment plan update was 10 days late.
Patient # 2 was admitted on June 18, 2010. The patient had a treatment plan update documented on October 1, 2010. The next treatment plan update was due December 1, 2010. The facility documented the next treatment plan update on February 2, 2011. The treatment plan update was two months late.
Patient # 3 was admitted on February 25, 2009. The patient had a treatment plan update documented on December 16, 2010. The next treatment plan update was due February 16, 2011. The facility documented the next treatment plan update on March 17, 2011. The treatment plan update was 19 days late. The next treatment plan update was due May 17, 2011. The facility documented the next treatment plan update on May 31, 2011. The treatment plan update was 14 days late.
Patient # 8 was admitted on May 9, 2011. The patient had a treatment plan documented on July 25, 2011. The treatment plan update was due September 25, 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 Program Director reviewed the regulations and Habit OPCO policies regarding the updating of treatment plans at the general staff meeting on November 2, 2011. The Clinical Director will ensure that the report of all treatment plan updates due is run via the treatment management software (SMART) each Monday. Any treatment plan updates that are due within the coming two weeks 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)(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 four patient records.
The findings include:
Nine patient records were reviewed on October 12, 2011. Per agency policy, discharge summaries are due within one week of discharge. Discharge summaries were required in four patient records. The facility did not document a discharge summary within one week of discharge in patient records # 2 and 3. .
Client # 2 was admitted on June 18, 2010 and was discharged on April 5, 2011. The discharge summary was due by April 12, 2011 The discharge summary was completed on April 29, 2011.
Client # 3 was admitted on February 25, 2009 and was discharged on July 18, 2011. The discharge summary was due by July 25, 2011 The discharge summary was completed on October 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. |