INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 21, 2015 through September 23, 2015 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the project's Staffing Requirement Facility Summary Reports (SRFSR), the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings inclued:
The Staffing Requirements Facility Summary Reports for the 4 facilities contained within the project were reviewed on September 21, 2015. The equivalent of 22 full-time counselors were employed within the project at the time of the inspection. This would require at least 2 full-time clinical supervisor.
The project's SRFSRs listed a total of 2 clinical supervisors, who also were listed as counselors and having a full caseload; therefore, they are unable to provide full-time clinical supervision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Center Director will submit a Personnel Action Request to human resources on 10/12/15. This Personnel Action Request being submitted to hire an additional clinician, or counselor assistant. This staffing action will allow for the existing clinical supervisors caseload to be transferred to the new hire, while also ensuring that the counselor?s caseload does not exceed 35:1. When the hiring process is completed, this will create a dynamic for greater supervision and case review by the clinical supervisors, who will carry a caseload of no more than 5 patients. The Center Director will be responsible for ensuring that the action plan is implemented as well as continuously monitor the 8:1 counselor to clinical supervisor ratio, with the clinical supervisor, to ensure that the facility maintains compliance with the regulated ratio. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the facility's Staffing Requirements Facility Summary Report (SRFSR) and a review of the personnel training files, the facility failed to ensure that all personnel received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum within the regulatory time frames.
The findings include:
The SRFSR form, completed by the facility, and personnel training files were reviewed on September 21, 2015. The facility failed to provide HIV/AIDS training for one of seventeen staff employed, specifically employee #3.
Employee #3 was hired as a counselor on June 16, 2014. HIV/AIDS training and TB/STD and other health related topics trainings were due to be completed no later than June 16, 2015. However, there was no documentation of either training on the SRFSR, as well as in the employee's training file.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 10/9/15, all newly hired staff will complete HIV/AIDS training within the first year of hire, in accordance with the State regulation. Office Manager will monitor all training requirements on a quarterly basis and report updates to the Clinic Director via a quarterly training report.
Employee #3 provided notice of terminating her employment and her scheduled DDAP trainings have been canceled. |
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 client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in two of fifteen client records reviewed.
The findings included:
Fifteen client records requiring complete informed and voluntary consent to release information forms were reviewed on September 21, 2015 through September 23, 2015. The facility failed to ensure that an informed and voluntary consent to release information form was obtained in client records, #8 and 9.
Client #8 was admitted into outpatient drug-free treatment on July 17, 2015 and was still an active client at the time of the inspection. There was no client signed/dated consent to release information form for the funding source, prior to the release of information, documented in the client record as of the date of the inspection.
Client #9 was admitted into outpatient drug-free treatment on October 30, 2014 and was discharged on February 11, 2015. There was no client signed/dated consent to release information form for the funding source, prior to the release of information, documented in the client record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In 2013, the Receipt of Information and Agreement form was updated as a result of changes in Federal Guidelines regarding confidentiality of electronic health records. This form also serves as a consent for billing the funding source. As of 10/9/15, all admissions, inclusive of Drug-Free outpatient, will sign this form upon admission. This will ensure proper consent is obtained and documented in the EMR.
1. The patients in question have since been discharged from the program.
2. The intake counselor will ensure all patients, inclusive of drug-free admissions, will have the proper consents signed/dated upon admission.
3 & 4. As of 10/26/15, the Clinical Supervisor will check the EMR upon completion of the intake to ensure the proper documentation has been signed/dated by the patient. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of client records, the facility failed to document an annual evaluation of the patient in three of fifteen client records reviewed.
The findings include:
Fifteen client records were reviewed on September 21, 2015 through September 23, 2015. Thirteen client records pertained to the narcotic treatment program and of the thirteen client records, eight client records required documentation of an annual evaluation. The facility failed to have an annual evaluation documented by the counselor in client records, #11, 12, and 14.
Client #11 was admitted into the narcotic treatment program on September 15, 2010 and was discharged on June 15, 2015. The last documented clinical annual evaluation in the client chart was dated 09/21/2011. There was no other annual evaluation in the chart as of the date of the inspection.
Client #12 was admitted into the narcotic treatment program on November 8, 2013 and was discharged on January 13, 2015. The clinical annual evaluation was due to be completed on the anniversary date of 11/08/2014; however, there was no annual evaluation in the client chart at the time of the inspection.
Client #14 was admitted into the narcotic treatment program on November 25, 2013 and was discharged on June 15, 2015. The clinical annual evaluation was due to be completed on the anniversary date of 11/25/2014; however, there was no annual evaluation in the client chart at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 10/9/15, Clinical Supervisor will monitor Annual Evaluations due on a weekly basis in supervision with staff. This will be accomplished by utilizing the Services Due report via the EMR for respective staff. Weekly review of evaluations will be completed by the CS to ensure completion and signatures will be verified. |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the 60-day regulatory period as required by Chapter 709 in seven of fifteen client records reviewed.
The findings include:
Fifteen client records were reviewed on September 21, 2015 through September 23, 2015. Thirteen client records pertained to the narcotic treatment program and required 60-day treatment plan updates. The facility failed to document 60-day treatment plan updates in client record #'s 3, 4, 5, 7, 12, 14, and 15.
Client #3 was admitted into the narcotic treatment program on July 30, 2012 and was still an active client as of the date of the on-site inspection. Treatment plan updates were completed on 01/28/15, 04/15/15, 5/6/15 and 7/22/15. These treatment plan updates were not completed within the 60-day timeframe as required in Chapter 709.
Client #4 was admitted into the narcotic treatment program on December 8, 2008 and was still an active client as of the date of the on-site inspection. Treatment plan updates were completed on 11/07/14, 02/01/15, 04/16/15, 06/29/15 and 09/10/15. These treatment plan updates were not completed within the 60-day timeframe as required in Chapter 709.
Client #5 was admitted into the narcotic treatment program on June 4, 2012 and was still an active client as of the date of the on-site inspection. Treatment plan updates were completed on 09/22/14, 12/08/14, 02/05/15, 04/17/15, 05/13/15 and 07/24/15. These treatment plan updates were not completed within the 60-day timeframe as required in Chapter 709.
Client #7 was admitted into the narcotic treatment program on March 22, 2015 and was still an active client as of the date of the on-site inspection. The initial treatment plan was completed on 05/05/15 and the first update was completed on 07/22/15. The treatment plan update was not completed within the 60-day timeframe as required in Chapter 709.
Client #12 was admitted into the narcotic treatment program on November 8, 2013 and was discharged on January 13, 2015. A treatment plan update was completed on 08/04/14 and the next update was completed on 12/09/14. The treatment plan update was not completed within the 60-day timeframe as required in Chapter 709.
Client #14 was admitted into the narcotic treatment program on November 25, 2013 and was discharged on June 15, 2015. A treatment plan update was completed on 12/26/14 and the next update was completed on 04/03/15. The treatment plan update was not completed within the 60-day timeframe as required in Chapter 709.
Client #15 was admitted into the narcotic treatment program on April 16, 2014 and was discharged on May 4, 2015. A treatment plan update was completed on 02/05/15 and the next update was due to be completed no later than 04/05/15; however, there was no update documented in the client chart at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 10/9/15, all treatment plan updates due will be reviewed weekly by the Clinical Supervisor with respective staff. Timeliness of documentation will be monitored and addressed in supervision weekly as well. Clinic Director will generate weekly reports via the EMR system to monitor and address issues accordingly. |
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 a review of client records, the facility failed to document an individual treatment and rehabilitation plan developed with the client in one of two outpatient drug-free client records reviewed.
The findings include:
Fifteen client records were reviewed on September 21, 2015 through September 23, 2015; whereas, two client records pertained to outpatient drug-free treatment and both required documentation of the individual treatment plan developed with the client's input. The facility failed to document the comprehensive treatment plan in client record #9.
Client #9 was admitted into outpatient drug-free treatment on October 30, 2014 and was discharged on February 11, 2015. The preliminary treatment plan was completed on 10/30/2014 during the intake process. The comprehensive individual treatment and rehabilitation plan was not completed, signed, and dated by the counselor until 02/11/2015, which was the day the client was discharged.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 10/9/15, all initial comprehensive treatment plans due will be reviewed weekly by the Clinical Supervisor with respective staff. CS will review plans for timeliness and patient input via the EMR. Any issues will be addressed with staff in weekly supervision ongoing. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes case consultation notes and follow-up information in one of two outpatient drug-free client records reviewed.
The findings include:
Fifteen client records were reviewed on September 21, 2015 through September 23, 2015. Two client records pertained to the outpatient drug-free activity, with both records requiring a complete client record. The facility did not provide a complete client record for client record #9.
Client #9 was admitted into treatment on October 30, 2014 and was discharged on February 11, 2015. The facility failed to include documentation of case consultation notes and follow-up information in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 10/9/15, all required documentation, inclusive of case consults and follow-up will be reviewed weekly by the Clinical Supervisor with respective staff. This will be accomplished by utilizing the Services Due report generated by the EMR. Any issues related to timeliness of submission for any documentation will be addressed/documented in weekly supervision. |