INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 15, 2015 through September 17, 2015 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:
|
Plan of Correction
|
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.
|
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 8, 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 supervisors.
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.
|
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.
|
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 training using a Department approved curriculum within the regulatory time frames.
The findings include:
The SRFSR form completed by the facility and a review of personnel training files were reviewed on September 15, 2015. The facility failed to provide HIV/AIDS training for one of eighteen staff employed, specifically employee #5.
Employee #5 was hired as a counselor on July 21, 2014. HIV/AIDS training was due to be completed no later than July 21, 2015. However, there was no documentation of HIV/AIDS training on the SRFSR, as well as in the employee's training file.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Employee #5 completed the HIV/AIDS training on September 25, 2015. Certificate of attendance has been placed in the HR file accordingly. All newly hired staff will complete the required trainings with the first year of hire, as required by the State regulations. Clinic Director will monitor accordingly. |
705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
|
Observations
Based on observation during the physical plant inspection, the facility failed to keep the grounds of the facility free from any danger to health and safety of the clients and staff.
The findings include:
A physical plant inspection was conducted on September 17, 2015. It was during the inspection, it was observed that a pane of glass, roughly the size of 3 1/2 feet X 3 1/2 feet, was broken. Half of the glass was gone; however, the other half was still attached with sharp edges of broken glass being exposed. Therefore, there is the possibility of a patient or staffmember to be severely cut or injured.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Pottstown Glass Co. is scheduled to replace the window today (10/9/15.) Any future repeat incidents will be managed immediately by the Clinic Director to ensure the safety of patients and staff, as opposed to waiting for the landlord to respond. |
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.
|
Observations
Based on a review of client records, the facility failed to either document an annual evaluation of the patient or failed to have the medical director sign and date the evaluation in three of nine client records reviewed.
The findings include:
Seventeen client records were reviewed on September 15, 2015 through September 17, 2015. Nine client records required documentation of an annual evaluation signed and dated by the counselor and the medical director. The facility failed to have the counselor or medical director sign and date the annual evaluation in client records, #1 and 2. Additionally, the facility failed to document an annual evaluation in client record #10.
Client #1 was admitted into treatment on September 9, 2014 and was still an active client as of the date of the on-site inspection. There was an annual evaluation completed on 09/14/2015; however, the evaluation was not signed and dated by the medical director as of the date of the inspection.
Client #2 was admitted into treatment on April 17, 2014 and was still an active client as of the date of the on-site inspection. There was an annual evaluation completed on 09/09/2015; however, the evaluation was not signed and dated by the primary counselor and the medical director as of the date of the inspection.
Client #10 was admitted into treatment on July 15, 2014 and was still an active client as of the date of the on-site inspection. An annual evaluation was due to be completed by 07/15/2015; however, there was no documentation of an annual evaluation in the client record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beginning 10/9/15, Clinical Supervisor will monitor Annual Evaluations due on a weekly basis in supervision with staff. Weekly review of evaluations will be completed by the CS and signatures will be verified. Clinic Director will monitor signature of Clinical Supervisor and MD in the EMR ongoing. |
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).
|
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 four of seventeen client records reviewed.
The findings include:
Seventeen client records requiring documentation of treatment plan updates within the regulatory timeframe were reviewed on September 15, 2015 through September 17, 2015. The facility failed to document 60-day treatment plan updates in client record #'s preliminary treatment and rehabilitation plans in client records #4, 5, 6, and 10.
Client #4 was admitted into treatment on November 24, 2014 and was still an active client as of the date of the on-site inspection. A treatment plan update was completed on 04/27/2015 and the next treatment plan was completed on 07/27/2015, which was outside of the 60-day timeframe required in Chapter 709.
Client #5 was admitted into treatment on March 09, 2015 and was still an active client as of the date of the on-site inspection. A treatment plan update was completed on 06/26/2015 and the next treatment plan was to be completed by 08/26/2015. However, the treatment plan was not completed until 09/03/2015.
Client #6 was admitted into treatment on December 16, 2014 and was still an active client as of the date of the on-site inspection. A treatment plan update was completed on 05/27/2015 and the next treatment plan was completed on 07/04/2015, which was outside of the 60-day timeframe required in Chapter 709. Additionally, a treatment plan update was due to be completed by 09/03/2015; however, there was no update completed at the time of the inspection.
Client #10 was admitted into treatment on July 15, 2014 and was discharged February 12, 2015. The comprehensive treatment plan was completed on 07/21/2014 and an update was due to be completed by 09/21/2014. However, the treatment plan update was not documented in the client chart until 10/15/2014.
These findings were reviewed with facility staff during the licensing process.
|
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. Clinical Supervisor will generate weekly reports via the EMR system to monitor and address issues accordingly.
Of the client records reviewed and noted, client #6 received a treatment plan update on 9/18/15. Subsequent plan is scheduled for 11/16/15. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
|
Observations
Based on a review of client records, the facility failed to provide documentation of a consent to treatment form as part of their intake procedures in two of two client records reviewed.
The findings include:
Two client records requiring client signed consent to treatment forms were reviewed on September 15, 2015 through September 17, 2015. There was no documentation of consent to treat forms in client records, #8 and 18.
Client #8 was admitted into treatment on August 18, 2015 and was still an active client at the time of the inspection. There was no documentation of a signed and dated consent to treatment form in the client record as of the date of the inspection.
Client #18 was admitted into treatment on June 24, 2015 and was discharged on September 14, 2015. There was no documentation of a signed and dated consent to treatment form in the client record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beginning 10/9/15, Consent to treat form will be signed upon intake for both MMTP and Drug-Free patients. This is inclusive of signing a consent to treat when transferring from MMTP to Drug Free Outpatient services.
Of the patient records reviewed, #8 and #18 have both been discharged, one of which was an active patient at the time of the inspection. We have since obtained an Informed Consent document to utilize for all Drug-Free admissions moving forward. |