INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted from October 17, 2016 to October 19, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records on October 17, 2016, it was determined that the project director did not meet the experiential requirements for the position. Considering the educational attainment of the current project director, he is required to have at least three years of experience in a human service agency, which includes supervision, direct service, and program planning. At the time of the inspection, the project director had no documented experience providing direct services.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director role will be transition to Jonathon Wasp effective 11/14/2016. Mr. Wasp meets all of the qualifications identified in the regulations including direct service. A formal notification will be submitted to the department by Mr. Wasp along with supporting documentation validating his qualifications for the role. |
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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #4 and #7 received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee #4 was hired as a counselor on September 28, 2015 and was due to have the HIV/AIDS training no later than September 28, 2016. There was no documentation in the personnel file of completion of the HIV/AIDS training as of the date of the inspection.
Employee #7 was hired as a counselor on July 7, 2015 and was due to have the HIV/AIDS training no later than July 7, 2016. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
As of 10/19/16, 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.
Since the inspection, Employees #4 and #7 have been monitoring the DDAP training website weekly, as has the Clinical Supervisor. As soon as the training becomes available, the staff will complete as required and obtain the necessary verification of such. The training will be completed no later than the first available date within our region or neighboring area. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection on October 18, 2016, it was observed that the facility failed to ensure that the carpets in the large group room downstairs and five counselor offices upstairs were kept in a sanitary and clean manner. The carpeting in each room was dirty and had large stains.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 10/19/16, the carpets in the facility will be professionally cleaned on a quarterly basis. The initial cleaning will occur before the end of Q4 2016 and prior to the end of each quarter thereafter. Receipts will be kept by the Office Manager as verification and can be viewed upon the next site inspection or as requested. The Director will ensure this is conducted quarterly via review of receipts for services. |
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.
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Observations
A review of the September 2015 through September 2016 fire drill logs was conducted during the onsite inspection. The facility failed to conduct unannounced drills during the 2016 months of January, February, and March, as well as September 2015. Additionally, there were several fire drill logs that were missing components as follows:
1) Logs for the 2015 months of October, November, and December, as well as logs for the 2016 months of April, May, and June did not include the exit route used and whether a fire alarm or smoke detector was operative at the time of the drill.
2) Logs for the 2016 months of April, May, June, July, and September did not include the number of persons evacuated.
3) The log for August 2016 did not include the whether the fire alarm or smoke detector was operative at the time of the drill.
4) The log for July 2016 did not include the time of the drill.
5) The log for September 2016 did not include the exit route used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning with the monthly fire drill in November, 2016, a revised form will be utilized and will reflect the following additional information:
Exit route
Number of persons evacuated
Fire alarm/smoke detector operative
All information, inclusive of the time of each drill, will be recorded by the and reviewed monthly by the Office Manager, as well as during quarterly Safety Committee meetings.
Unannounced monthly fire drills will be conducted by Administrative staff and monitored by the Office Manager via monthly report. Reports will also be reviewed by the Director on a quarterly basis. |
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.
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Observations
Based on the review of patient records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in patient records, #1, 6, 9, and 11. Additionally, patient record #10 had disclosed patient information beyond what the signed consent to release information form permitted.
Patient #1 was admitted on January 25, 2016 and was still an active patient at the time of the inspection. The record did not contain a consent for the funding source, despite evidence that billing was submitted.
Patient #6 was admitted on September 18, 2013 and was still an active client at the time of the inspection. The record did not contain a current consent for the funding source, despite evidence that billing was submitted. The most recent signed consent form expired on January 31, 2016.
Patient #9 was admitted on January 5, 2016 and was active at the time of the inspection. The record did not contain a consent for the funding source, despite evidence that billing was submitted.
Patient #10 was admitted on October 4, 2013 and was discharged on March 1, 2016. A consent form was signed by the patient on February 19, 2016 for another treatment provider that allowed for the release of treatment status-verification and prognosis. However, the record contained documentation of a facsimile sent to the provider on February 19, 2016 which included a treatment plan, dose history, and urinalysis results.
Patient #11 was admitted on October 20, 2014 and was discharged on October 29, 2015. The record contained documentation of a facsimile sent to another treatment provider that was of the patient's dosing record; however, there was no valid consent to release information form signed by the client prior to the disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All active patients will have signed consent forms for their respective funding source by November 30, 2016 in the EMR. All clinicians will have an additional training regarding confidentiality documented by 11/30/16, inclusive of review of proper disclosures. The Office Manager and the Clinical Supervisor will be responsible for ensuring the consent forms are in the EMR and the clinicians receive the additional training. The Office Manager will provide the Director with notification upon completion. |
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
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Observations
Based on the review of the physician timesheets for the months of May, June, July, and August 2016, the facility failed to provide at least one hour of physician time a week, on site for every ten patients for each week during May 2016 and June 2016.
During the week of May 8-14, 2016, the patient census was 229. The facility was required to provide at least 22.9 physician hours. There were 7.5 physician hours documented.
During the week of May 15-21, 2016, the patient census was 231. The facility was required to provide at least 23.1 physician hours. There were 18.5 physician hours documented.
During the week of May 22-28, 2016, the patient census was 232. The facility was required to provide at least 27.8 physician hours. There were 18.5 physician hours documented.
During the week of May 29, 2016-June 4, 2016, the patient census was 232. The facility was required to provide at least 23.2 physician hours. There were 11.5 physician hours documented.
During the week of June 5-11, 2016, the patient census was 232. The facility was required to provide at least 23.2 physician hours. There were 22.5 physician hours documented.
During the week of June 19-25, 2016, the patient census was 231. The facility was required to provide at least 23.1 physician hours. There were 22.5 physician hours documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of June 2016, the facility added a part-time CRNP to the team. As evidenced by physician timesheets in recent months, all required physician hours are now met in accordance with the 1:10 ratio on a weekly basis. In addition, the CRNP has been hired FT, effective 1/1/17, to further ensure this requirement is met in both Allentown and Pottstown facilities. |
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, patient records #1, 2, 3, 5, 6, 7, and 9 had treatment plan updates completed after the regulatory timeframe of 60 days at the time of the inspection.
Patient #1 was admitted on January 25, 2016 and was an active patient at the time of inspection. The comprehensive treatment and rehabilitation plan was completed on March 25, 2016. A treatment plan update was due no later than May 25, 2016, but was not completed until June 6, 2016. Additionally, another treatment plan update was due no later than August 6, 2016, but was not completed until October 7, 2016.
Patient #2 was admitted on March 22, 2015 and was an active patient at the time of inspection. A treatment plan update was completed on October 16, 2015, and an update was due no later than December 16, 2016, but was not completed until February 2, 2016. Additionally, another treatment plan update was due no later than April 2, 2016, but was not completed until June 6, 2016.
Patient #3 was admitted on October 26, 2009 and was discharged on September 29, 2016. A treatment plan update was completed on November 24, 2015, and an update was due no later than January 24, 2016, but was not completed until March 23, 2016. Additionally, an update was completed on March 25, 2016 and an update was due no later than May 25, 2016, but was not completed until June 30, 2016.
Patient #5 was admitted on February 27, 2013 and was discharged on May 31, 2016. A treatment plan update was completed on February 15, 2016 and an update was due no later than April 15, 2016, but was not completed until April 27, 2016.
Patient #6 was admitted on September 18, 2013 and was an active patient at the time of inspection. A treatment plan update was completed on June 20, 2016 and an update was due no later than August 20, 2016, but was not completed until September 6, 2016.
Patient #7 was admitted on May 25, 2016 and was discharged on September 28, 2016. The comprehensive treatment and rehabilitation plan was completed on June 25, 2016. A treatment plan update was due no later than August 25, 2016, but was not completed until September 12, 2016.
Patient #9 was admitted on January 5, 2016 and was an active patient at the time of inspection. A treatment plan update was completed on April 22, 2016 and the next update was due no later than June 22, 2016, but the update was not completed until July 27, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 10/19/16, 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. |