INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted on January 5-6, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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:
|
Plan of Correction
|
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report, Employee #4 was hired as a counselor on October 24, 2019 and was still acting in that position. Employee #4 was reported to have 37.5 hours per week devoted to their 39 clients on their caseload.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by 37.5. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE.
The FTE counselor's caseload calculation is as follows: 37.5/37.5 = 1(FTE); 39/1 = 39, which equals to a client/counselor ratio of 39:1. The FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
Employee #8 was hired as a counselor on June 30, 2020 and was still acting in that position. Employee #8 was reported to have 37.5 hours per week devoted to their 37 clients.
The FTE counselor ' s caseload calculation is as follows: 37.5/37.5 = 1(FTE); 37/1 = 37, which equals to a client/counselor ratio of 37:1. The FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Since staffing requirements were sent to DDAP, a new clinician has started. Based on the current census and those who meet the criteria of licensure alert 01-14, the facility will meet the 35:1 requirement. The Clinical Supervisor will monitor ratio weekly, when assigning new admissions to counselors. The CTC Director will monitor census weekly to ensure compliance with this regulation and hire additional staff as needed. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of fire drills for 2020, the facility failed to conduct unannounced fire drills at least once a month.
There were no fire drills documented for the months of February, April, June and August 2020.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from a licensing inspection conducted on November 22, 2019.
|
Plan of Correction
The Health and Safety Liaison will conduct at minimum of one Fire drill per month and document the drill using the designated Emergency drill form, which notes the time the fire drill took place, the time it took to evacuate, the exit route used, the number of people in the facility at the time of the fire drill, and any problems that may have been encountered during the drill. The CTC Director will monitor compliance in this area by inspecting the extinguishers and reviewing the Health and Safety documentation quarterly. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of fire drills for 2020, the facility failed to prepare alternate exit routes to be used during fire drills.
There were no alternate exits documented on fire drills completed from January 2020 through October 2020.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Health and Safety Liaison will conduct at minimum one Fire drill per month and document the alternate exits in the drill using the designated Emergency drill form. The CTC Director will monitor compliance in this area by ensuring that alternative exit routes are used during the fire drills. |
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.
|
Observations
Based on a review of fire drills on for 2020, the facility failed to maintain a fire drill record that included whether the facility set off a fire alarm or smoke detector during each fire drill.
There was no documentation if a fire alarm or smoke detector were set on the fire drill record completed from January through October 2020.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Health and Safety Liaison will conduct at minimum one Fire drill per month, by sounding an alarm to initiate the start of the drill, and document the drill using the designated Emergency drill form. Liaison will also document whether a smoke detector or fire alarm was used to initiate the drill. The CTC Director will monitor compliance in this area by inspecting the extinguishers and reviewing the Health and Safety documentation quarterly. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
|
Observations
Based on a review of physician hours on November 12-13, 2020 the narcotic treatment program failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.
From July 27- August 2, 2020 the program had a census of 273 which required 27.3 physician hours, the program was short 1.53 physician hours.
From August 10-16, 2020 the program had a census of 273 which required 27.3 physician hours, the program was short 1.1 physician hours.
From August 24-30, 2020 the program had a census of 272 which required 27.2 physician hours, the program was short 1.56 physician hours.
From October 5-11, 2020 the program had a census of 289 which required 28.9 physician hours, the program was short 2.4 physician hours.
These findings were reviewed with program staff during the licensing process.
This is a repeat citation from licensing inspections November 22, 2019, December 6, 2018, November 28, 2017 and October 19, 2016.
|
Plan of Correction
The CTC Director will ensure that the Program Physician(s) provide at least 1 hour per week onsite for every ten patients. A Physician schedule has been developed as of 2/01/2021 and will be submitted to the medical staff monthly to ensure there is adequate coverage of CRNP and MD per census requirements. The CTC Director will monitor the monthly calendar to ensure there is adequate coverage between MDs and CRNP. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
Based on a review of twelve client records, it was determined that the facility failed to provide documentation that seven out of the twelve patients reviewed had received an average of 2.5 hours of psychotherapy per month during the patient's first 2 years, 1 hour of which should be individual psychotherapy.
Patient #2 was admitted on November 16, 2020 and was current at the time of the inspection. This patient had no psychotherapy in November 2020 and 1 hour of individual and 1 hour of group psychotherapy in December 2020. There was no documentation of client no shows or cancellations during those time periods.
Patient #5 was admitted on July 23, 2019 and was current at the time of the inspection. This patient had 1.5 hours of individual psychotherapy for October, November and December 2020 however had no group psychotherapy hours for these months. There was no documentation of client no shows or cancellations during those time periods.
Patient #6 was admitted on July 25, 2019 and was a current at the time of the inspection. This patient had 1 hour of individual and 1 hour of grouop pyschotherapy in both October and December. There was no psychotherapy documented for November 2019. There was no documentation of client no shows or cancellations during those time periods.
Patient #11 was admitted on September 25, 2019 and was a current patient at the time of the inspection. This patient had 1 hour of group and 45 minutes of individual psychotherapy in October and 45 minutes of individual pyschotherapy in November. There was no psychotherapy documented for December 2019. There was no documentation of client no shows or cancellations during those time periods.
Patient #12 was admitted on November 11, 2019 and was a current patient at the time of the inspection. This patient had 45 minutes of individual pyschotherapy in October and November and no other counseling documented. There was no documentation of client no shows or cancellations during those time periods.
Patient #14 was admitted on March 16, 2020 and was involuntarily discharged on November 4, 2020. This patient had no therapy documented for July, August and October 2020 and 1 hour of group psychotherapy for September 2020. There was no documentation of client no shows or cancellations during those time periods.
Patient #15 was admitted on July 17, 2019 and was involuntarily discharged on March 10, 2020. This patient had no counseling documented for December 2019, January 2020 and February 2020. There was no documentation of client no shows or cancellations during those time periods.
These findings were reviewed with facility staff during the licensing process.
These are repeat citations from inspections conducted on November 11, 2019, December 6, 2018 and November 28, 2017.
|
Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services. The Clinical Supervisor will review the requirements for counseling services with all counselors weekly in in supervision. Counselors run their Direct Services Analysis reports in SMART and turn into the Clinical Supervisor weekly, noting the number of hours of both individual and group counseling that each patient is receiving per month. The Clinical Supervisor will review the reports in individual and group supervision monthly. Ongoing non-compliance in meeting the Direct Services requirement will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process. |