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 11 through October 12, 2011 licensure renewal inspection. The follow-up inspection was conducted on May 29, 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. - 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.
This remained out of compliance at the time of the follow-up conducted on May 29, 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 29, 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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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 the review of patient records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in three of three patient records reviewed.
The findings included:
Eight patient records were reviewed May 29, 2012. Three records were reviewed regarding release of information documentation. The facility failed to ensure that an informed and voluntary consent to release information was obtained in patient records # 1, 5, and 7.
A review of patient record # 1 revealed information was released to a funding source on November 16, 2011 and November 21, 2012. The patient did not sign a release prior to releasing information for the funding entity.
A review of patient record # 5 revealed information was released to a funding source on November 23, 2011 and December 8, 2011. The patient did not sign a release prior to releasing information for the funding entity.
A review of patient record # 7 revealed information was released to a funding source on January 31, 2012. The patient did not sign a release prior to releasing information for the funding entity.
This finding was discussed with the facility director, lead counselor, and Director of Pennsylvania Operations and was not disputed.
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Plan of Correction
The Program/Clinical Director reviewed the findings of policy 709.28 with the clinical team during group supervision session on Thursday, June 7, 2012.
The Program/Clinical Director will ensure that an informed and voluntary consent to release information for all funding sources will be signed by individuals during the intake process.
Additionally, chart audits will pay closer attention to signed, informed and voluntary consent to release information for all funding sources.
A thorough review of policy/procedure 709.28 will occur again during clinical group supervision on July 9, 2012 |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on the review of patient records, the narcotic treatment program failed to document all efforts to retain the patient in the program prior to initiating an involuntary termination one of one patient records.
The findings include:
Eight patient records were reviewed on May 29, 2012. Documentation that an involuntary termination was initiated only when all other efforts to retain the patient in the program have failed was required in one patient record. The facility did not document the efforts made to retain the patient in patient record #3. The treatment plan and progress notes in the record did not address any efforts to retain the patient in treatment.
Patient # 3 was admitted on November 16, 2011 and discharged on May 4, 2012. The patient was a self-pay and record documentation indicated the patient was in arrears paying for treatment services. According to the documentation, the patient was initially on a self-requested detoxification from methadone. On March 28, 2012, the doctor wrote an order to stop the patient's detoxification request. On March 28, 2012 the patient was presented with a notice of a non-emergency discharge for failure to maintain the financial obligation to the facility. The notice stated that the patient did not have medical insurance and had arranged for a payment plan. The patient had agreed to make weekly payments of $125. This payment included the weekly fee of $105 plus $20 towards the patient's arrears until he became current with his payments. Based on the review of the patient's account, he owed $400 on March 27, 2012. The patient appealed the involuntary termination on March 28, 2012. Records showed that the patient made a payment of $120 on March 4, 2012, $100 on March 12, 2012, $100 on March 24, 2012, and $150 on March 27, 2012. The patient stated in his appeal that he was working on obtaining medical assistance. The patient's appeal was denied and he was informed on March 30, 2012 that he would begin a 21 day detoxification on April 3, 2012. Patient was informed that if he would pay his balance prior to completing his detox the discharge process would be stopped.
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Plan of Correction
The Program Director reviewed policy 715.21 with the PA Director of Operations during and after the site visit on May 29, 2012.
The Program Director will impliment an assessment tool for self-pay clients designed to help us determine:(a)patients ability to pay, (b) barriers to payment, and (c)willingness to pay.
Furthermore, clinicians will be trained on how to address non-payment, to include documentation of reasons for non-payment and intervention efforts. Treatment compliance contracts will be used in situations of non-payment when the patient has been determined to have the means to pay, however are simply unwilling to do so. Only in those cases would we initiate discharge. A staff trainig will be held on July 20, 2012 to instruct staff on assessing, documenting, and addressing situations of non-payment.
Habit OPCO will ensure that discharge recommendations are compliant with 715.21 by adding language to treatment plans that clearly identifies the need to maintain compliance with Habit OPCO established rules. This will ensure that discharges are always in compliance with treatment plan compliance as required by 715.21
Ongoing compliance will be monitored by the Facility Director and/or lead clinician through bi-weekly random chart audits.
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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:
Eight records were reviewed May 29, 2011. Eight 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 # 8.
Patient # 8 was readmitted on January 31, 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 July 16, 2010.
This finding was discussed with the facility director and lead counselor 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.
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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. Eight patient records were reviewed on May 29, 2012. All 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 one of eight records reviewed, specifically record # 8.
Patient # 8 was readmitted on January 31, 2012. An individual treatment and rehabilitation plan was due by March 2, 2012. The individual treatment and rehabilitation plan was completed on March 29, 2012 by the counselor. The treatment plan was reviewed with the client on April 2, 2012. The plan was 27 days late.
This finding was reviewed with the facility director and lead counselor and was not disputed.
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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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709.93(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 three of five patient records.
The findings include:
Eight patient records were reviewed on May 29, 2012. Per agency policy, discharge summaries are due within one week of discharge. Discharge summaries were required in five patient records. The facility did not document a discharge summary within one week of discharge in patient records # 1, 2 and 3.
Patient # 1 was admitted on November 21, 2011 and was discharged on February 6, 2012. The discharge summary was due by February 13, 2012. The discharge summary was completed on March 20, 2012.
Patient # 2 was admitted on November 29, 2011 and was discharged on February 6, 2012. The discharge summary was due by February 13, 2012. The discharge summary was completed on March 20, 2012.
Patient # 3 was admitted on November 16, 2011 and discharged on May 4, 2012. The discharge summary was due by May 11, 2011. The facility failed to document a discharge summary in this patient record as of the date of the inspection.
This finding was discussed with the facility director and lead counselor and was not disputed.
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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.
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