INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 24, 2016 thru October 26, 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. - 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:
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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 24, 2016, it was determined that the project director of the facility 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. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on October 26, 2016 at 1:30 pm, the hot water temperature in the staff bathroom close to the lobby was measured at 128.5 degrees and the water temperature in the client bathroom close to the lobby was measured at 129.0 degrees.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In review of this issue, it was determined that there are two thermostats on the hot water heater. Once the second thermostat was adjusted, the temperature adjusted accordingly and this issue was resolved. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
A review of the October 2015 through September 2016 fire drill logs was conducted during the onsite inspection. The fire drill logs for the months of October 2015, February 2016, May 2016, and July 2016 failed to include the number of persons in the facility at the time of the drill and whether a fire alarm or smoke detector was operative at the time of the drill. The logs for all months, except February 2016 and September 2016, failed to include the exit route used. Additionally, the logs for November 2015, January 2016, March 2016, April 2016, June 2016, August 2016, and September 2016 did not state whether a fire alarm or smoke detector was operative at the time of the drill.
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.
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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.
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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, 2,3,4,5,6,7,8,10 and 11.
Patient #1 was admitted on December 9, 2013 and was discharged on March 17,2016. The record did not contain a consent for the funding source, despite evidence that billing was submitted.
Patient #2 was admitted on December 15, 2015 and was discharged March 16,2015. The record did not contain consent for the funding source, despite evidence that billing was submitted.
Patient #3 was admitted on October 28, 2015 and was discharged February 1,2016. The record did not contain consent for the funding source, despite evidence that billing was submitted
Patient #4 was admitted on July 7, 2016 and was active at time of inspection. The record did not contain a current consent for the funding source, despite evidence that billing was submitted
Patient #5 was admitted on July 23, 2012 and was active at time of inspection. A consent to release form was signed and dated on 07/7/16 to the funding source that allowed for the release of "requested information for insurance," which exceeds what is allowed by 4 PA Code 255.5.
Patient #6 was admitted on May 31, 2016 and was active at the time of inspection. The consent form for the funding source was signed 8/12/2016 and only allowed for the release of patients diagnosis, despite evidence that more information for billing was submitted.
Patient #7 was admitted on December 29, 2015 and was discharged on October 11, 2016. The record did not contain a consent for the funding source, despite evidence that billing was submitted.
Patient #8 was admitted on July 7, 2014 and was discharged on December 16, 2015. The record contain a consent for the funding source, despite evidence that billing was submitted.
Patient #10 was admitted on March 21, 2016 and was active at time of inspection. The record did not contain a current consent for the funding source, despite evidence that billing was submitted.
Patient #11 was admitted on August 11, 2014 and was active at time of inspection. The record did not contain a consent for the funding source, despite evidence that billing was submitted.
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 December 15, 2016 in the EMR. The Office Manager and the Clinical Supervisor will complete all ROIs for all active patients and patients will be prompted to sign thereafter. Moving forward, the Counselors will set up the initial releases for the funding sources during the time of intake to ensure completion during the admission process.
All clinicians will have an additional training regarding confidentiality documented by 11/30/16, inclusive of review of proper disclosures. The Clinical Supervisor will facilitate the training and the Office Manager will ensure training evals are completed for the HR files. |
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, August, September, and October 2016, the facility failed to provide at least one hour of physician time a week, on site for every ten patients during 11 weeks of the 24 weeks reviewed.
During the week of May 1-7, 2016, the patient census was 273. The facility was required to provide at least 27.3 physician hours. There were 25 physician hours documented.
During the week of May 8-14, 2016, the patient census was 271. The facility was required to provide at least 27.1 physician hours. There were 25 physician hours documented.
During the week of May 15-21, 2016, the patient census was 269. The facility was required to provide at least 26.9 physician hours. There were 25 physician hours documented.
During the week of May 22-28, 2016, the patient census was 271. The facility was required to provide at least 27.1 physician hours. There were 25 physician hours documented.
During the week of May 29-June 4, 2016, the patient census was 271. The facility was required to provide at least 27.1 physician hours. There were 20 physician hours documented.
During the week of June 5-11, 2016, the patient census was 274. The facility was required to provide at least 27.4 physician hours. There were 14 physician hours documented.
During the week of June 12-18, 2016, the patient census was 273. The facility was required to provide at least 27.3 physician hours. There were 24.5 physician hours documented.
During the week of June 26-July 2, 2016, the patient census was 272. The facility was required to provide at least 27.2 physician hours. There were 20 physician hours documented.
During the week of July 3-9, 2016, the patient census was 274. The facility was required to provide at least 27.4 physician hours. There were 18 physician hours documented.
During the week of August 27- September 3, 2016, the patient census was 271. The facility was required to provide at least 27.1 physician hours. There were 20.5 physician hours documented.
During the week of September 4-10, 2016, the patient census was 273. The facility was required to provide at least 27.3 physician hours. There were 25 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. |
715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on review of patient records, patient #2's record did not contain documentation that the facility sent the required patient information, which is to include admission date, medical and psychosocial summaries, dosage level, urinalysis results, exception requests, and current status of patient, to the receiving narcotic treatment program. Patient #2 was admitted on December 15, 2015 and was transferred to another treatment facility on March 15, 2016.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Beginning 12/1/16, the required patient information to be sent to a receiving narcotic treatment program will be documented via a checklist and signed by the sending Counselor. This checklist will include admission date, medical and psychosocial summaries, dosage level, urinalysis results, exception requests, and current status of patient. |
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 #5, 8, 10 and 11 had treatment plan updates completed after the regulatory timeframe or missing at the time of the inspection.
Patient #5 was admitted on July 23, 2012 and was an active patient at time of inspection. A treatment plan update was completed March 23, 2016 and the next update was due no later than May 23, 2016. However, the next update was not completed until June 22, 2016.
Patient #8 was admitted on July 7, 2014 and was administratively discharged on December 16, 2016. A treatment plan update was completed September 13, 2016 and the next update was due no later than November 13, 2016. However, the next update was not completed until December 14, 2016.
Patient #10 was admitted on March 21, 2016 and was an active patient at time of inspection. A treatment plan update was completed on April 25, 2016 and the next update was due no later than June 25, 2016; however, the next documented update was not completed until July 7, 2016.
Patient #11 was admitted on August 11, 2014 and was an active patient at time of inspection. A treatment plan update was completed on March 14, 2016 and the next update was due no later than May 14, 2016; however, the next documented update was not completed until June 13, 2016. The next update was due no later than August 13, 2016; however, the next documented update was not completed until August 30, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 10/28/16, 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. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of patient records, patient #'s 1, 6, 7, and 8 were identified as medical assistance clients and the facility failed to document the physician signature on the patient's treatment plan updates.
Patient #1 was admitted on December 9, 2013 and was discharged on March 17, 2016. The facility failed to document the physician signature on the patient's updated treatment plans, dated 3/9/2016 and 9/14/2015.
Patient #6 was admitted on May 31, 2016 and was active at time of inspection. The facility failed to document the physician signature on the patient's updated treatment plans, dated 8/31/2016 and 9/30/2016.
Patient #7 was admitted on December 29, 2015 and was discharged on October 11, 2016. The facility failed to document the physician signature on the patient's updated treatment plan, dated 3/22/2016.
Patient #8 was admitted on July 7, 2014 and was discharged on December 16, 2015. The facility failed to document the physician signature on the patient's updated treatment plan, dated 12/14/16.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
As current practice, the MD reviews all tx plan updates weekly. Beginning the week of 11/21/16, the MD will review updates 2x/week, schedule permitting, to ensure all are reviewed and signed accordingly.
MD will review and sign the treatment plan updates for client #6 by 11/30/16. |