INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 21, 2019 through November 22, 2019 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. 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel records during the onsite licensing inspection on November 21, 2019 through November 22, 2019, it was determined that the project failed to complete individual training plans for two out of eight employees reviewed.
Employee #3 was hired on June 2, 2014 and was a current employee at the time of the inspection. A written individual training plan was not completed for this employee for the 2019 training year.
Employee #7 was hired on April 22, 2018 and was a current employee at the time of the inspection. A written individual training plan was not completed for this employee for the 2019 training year.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A training plan was completed at Pottstown for Employee #3 by his supervisor there. Training plans will be developed upon hire and annually thereafter as we are going to a company wide common review date beginning January 2020. Employee #7 will have a training plan completed by 1/15/2020. The Clinic Director will complete quarterly employee file audits to ensure compliance with training plans for all staff. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of personnel records during the onsite licensing inspection on November 21, 2019 through November 22, 2019, it was determined that the project failed to ensure that a sufficient number of staff persons were certified in CPR and first aid. Only one clinical staff member had received a CPR and first aid certification.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinic Director will schedule an onsite CPR training for the entire staff that includes hands on instruction by 4/30/2020. The Clinic Director will ensure there is enough personel trained in CPR to cover the programs hours of operation. A nurse is onsite at all times that patients are in attendance at the clinic and every nurse is trained in CPR. The Clinic Director will monitor CPR certifications annually. |
705.27 (1) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a physical plan inspection conducted on November 22, 2019, it was determined that the facility failed to ensure that it is was free of rodent and insect infestations as evidenced by;
1) Rodent feces was on a desk in the facility.
2) Insects were observed in multiple traps throughout the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director had an exterminator out to address the infestation on 12/23/19. To ensure that the site remains free of rodent and insect infestation the program will have Ehrlich Pest Control perform maintenance three times per year (March, July, November) for preventative maintenance and upon request as needed. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection conducted on November 22, 2019, it was determined that the facility failed to ensure that the fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
1) Three ground floor fire extinguishers were last inspected in October 2018.
2) Two main floor fire extinguishers were last inspected in October 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director had Leheigh Valley Fire Protection out to do the inspection if the Fire Extinguishers on 12/23/19. The Health and Safety Liaison will inspect the Fire Extinguishers monthly as part of the monthly safety inspection and ensure that the annual inspection of the Fire Extinguishers occurs as required. The Clinic Director will monitor compliance in this area by inspecting the extinguishers and reviewing the Health and Safety documentation quarterly. |
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
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, it was determined that the facility failed to conduct unannounced fire drills monthly. The facility failed to conduct unannounced fire drills for the months of September 2019 and October 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Health and Safety Liaison will conduct at minimum one Fire drill per month and document the drill using the designated Emergency drill form. The Clinic Director will inspect the extinguishers and reviewi the Health and Safety documentation quarterly. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, the project failed to ensure that personnel records included annual written individual staff performance evaluations for two out of eight personnel records reviewed.
Employee #3 was hired June 2, 2014 and was a current employee at the time of the licensing inspection. An annual written individual staff performance evaluation was completed for this employee on March 12, 2018. The next annual written individual staff performance evaluation was to be complete no later than March 12, 2019; however, it was not documented as of the date of the inspection.
Employee #7 was hire April 22, 2018 and was a current employee at the time of the licensing inspection. An annual written individual staff performance evaluation was to be complete no later than April 22, 2019; however, it was not documented as of the date of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Annual evaluations for Employee #3 was completed by his supervisor in Pottstown and # 7 will be conducted by 12/31/19. The annual Performance Evaluations for all staff will be conducted on a new schedule where all evaluations will be completed by January each year. The Clinic Director will complete a year end evaluation Audit to ensure compliance. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, the project failed to inform clients that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Those reasons for removing sections shall be documented in the record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinic Director will work with the Director of Quality and Compliance to revise the Patient Rights to state that "The CTC Director may temporarily remove portions of the records prior to the inspection by the patient if the Director determines that the information may be detrimental if presented to the patient. Reasons for removing sections shall be documented in the record." The revision will be completed by 1/31/2020. The Clinic Director will review policy revisions during February 2020 All Staff Meeting. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, the project failed to develop and implement policies and procedures to respond to an unusual incident involving physical or sexual assault by staff or a client.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Clinic Director will work with the Director of Quality and Compliance to revise policy 7.1.18 to include responding to sexual assault. The revision will be completed by 1/31/2020. The Clinic Director will review all policy revisions during the February 2020 All Staff Meeting. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, the project failed to develop and implement policies and procedures to respond to an unusual incident involving selling or use of illicit drugs on the premises.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Clinic Director will work with the Director of Quality and Compliance to develop a policy to address how the facility will respond to Selling or use of illicit drugs on the premises. The policy will be developed by 1/31/2020. The Clinic Director will review all policy revisions during the February 2020 All Staff Meeting. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, the project failed to develop and implement policies and procedures to respond to an unusual incident involving death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinic Director will work with the Director of Quality and Compliance to revise the Sentinel Event policy (3.4.1) in the PA Operations manual to meet the requirements of the regulation. The revision will be completed by 1/31/2020. The Clinic Director will review all policy revisions during the February 2020 All Staff Meeting. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, the project failed to develop and implement policies and procedures to respond to an unusual incident involving an event at the facility requiring the presence of policy, fire or ambulance personnel.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinic Director will work with the Director of Quality and Compliance to revise Emergency Action Plan policy (9.6) in the PA Operations manual to meet the requirements of the regulation. The revision will be completed by 1/31/2020. The Clinic Director will review all policy revisions during the February 2020 All Staff Meeting. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
During a licensing inspection conducted on November 21, 2019 through November 22, 2019 the project failed to develop and implement procedures in responding to fire or structural damage to the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Regional
Director will work with the
Clinic Director, Quality &
Compliance Department staff as
well as with the Clinical
Support and Compliance staff
members to review the existing
procedures and ensure that
language is in place to respond
to fire or structural damage to
the facility. As with other
procedure related reviews and
re-drafts, such will be prepared
for review and approval by the
regional director by January 31,2020.
Additionally, such will be
followed up with a full staff
meeting and training to review
the re-drafted procedures. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
During a licensing inspection conducted November 21, 2019 through November 22, the project failed to develop and implement procedures in responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Regional
Director will work with the
Clinic Director, Quality &
Compliance Department staff as
well as with the Clinical
Support and Compliance staff
members to review the existing
procedures and ensure that
language is in place to respond
to an outbreak of a contagious
disease requiring Centers for
Disease Control (CDC)
notification.
As with other procedure related
reviews and re-drafts, such will
be prepared for review and
approval by the regional
director by January 31, 2020.
Additionally, such will be
followed up with a full staff
meeting and training to review
the re-drafted procedures. |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, the project ' s policy and procedure manual did not provide policies and procedures on documenting unusual incidents.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CTC has policies and procedures for Documentation of Unusual incidents including: Unusual Incident policy (3.4) and the Sentinel Event Policy (3.4.1) which are located in the PA Operations manual as well as Incident Reporting policy in the Risk Management manual. The CTC Director is responsible for ensuring compliance with these policies. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, the project ' s policy and procedure manual did not provide a policy and procedure to include the prompt review and identification of the cause directly or indirectly responsible unusual incident.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinic Director will work with the Director of Quality and Compliance to revise the Unusual incident policy (3.4) to clarify the procedure for prompt review and identification of the causes directly or indirectly responsible for the unusual incident. The revision will be completed by 1/31/2020. The Clinic Director will review all policy revisions during the February 2020 All Staff Meeting. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, the project ' s policy and procedure manual did not provide a policy and procedure to include the implementation of a timely and appropriate corrective action plan for an unusual incident, when indicated.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinic Director will work with the Director of Quality and Compliance to revise the Unusual incident policy (3.4) to clarify the procedure on the implementation of a timely and appropriate corrective action plan for an unusual incident, when indicated. The revision will be completed by 1/31/2020. The Clinic Director will review all policy revisions during the February 2020 All Staff Meeting. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, the project ' s policy and procedure manual did not provide a policy and procedure to include the ongoing monitoring of the corrective action plan for an unusual incident.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinic Director will work with the Director of Quality and Compliance to revise the Unusual incident policy (3.4) to clarify the procedure for ongoing monitoring of the corrective action plan for an unusual incident. The revision will be completed by 1/31/2020. The Clinic Director will review all policy revisions during the February 2020 All Staff Meeting. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, the project ' s policy and procedure manual did not provide a policy and procedure to include the reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinic Director will work with the Director of Quality and Compliance to revise the Unusual incident policy (3.4) to clarify that reporting of unusual incidents to external agencies is to be in compliance with State and Federal confidentiality laws. The revision will be completed by 1/31/2020. The Clinic Director will review all policy revisions during the February 2020 All Staff Meeting. |
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
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, the program failed to ensure that narcotic treatment physician services were provided at least 1 hour per week onsite for every ten patients
Based on the weekly census report for the week of October 6, 2019 through October 12, 2019, the program was to provide 22.7 narcotic treatment physician service hours. The program failed to provide documentation of coverage for 14.95 of the 22.7 narcotic treatment physician hours required for this week.
Based on the weekly census report for the week of October 13, 2019 through October 19, 2019, the program was to provide 22.4 narcotic treatment physician service hours. The program failed to provide documentation of coverage for 16.65 of the 22.4 narcotic treatment physician hours required for this week.
Based on the weekly census report for the week of October 20, 2019 through October 26, 2019, the program was to provide 22.4 narcotic treatment physician service hours. The program failed to provide documentation of coverage for 14.65 of the 22.4 narcotic treatment physician hours required for this week.
Based on the weekly census report for the week of October 27, 2019 through November 2, 2019, the program was to provide 22.4 narcotic treatment physician service hours. The program failed to provide documentation of coverage for 14.4 of the 22.4 narcotic treatment physician hours required for this week.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Clinic Director will ensure that the Program Physician(s) provide at least 1 hour per week onsite for every ten patients. Clinic Director will add/adjust physician hours to meet the required need. A Physician schedule has been developed as of 12/23/2019 and will be submitted to the medical staff monthly to ensure there is adequate coverage. Clinic Director will monitor the monthly calendar to ensure there is adequate coverage. |
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.
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Observations
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, it was determined that the program failed to provide documentation that 7 out of 14 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 #4 was admitted on April 4, 2019 and was discharged on September 26, 2019. This patient was missing 2.5 hours of psychotherapy for the month of April 2019, 1 hour for the month of May 2019, 1.75 for the month of June 2019, 2.5 for the month of July 2019, 1.75 for the month of August 2019 and 2.5 for the month of September. There was no documentation of client no shows or cancellations during those time periods.
Patient #5 was admitted on April 6, 2019 and was discharged on September 6, 2019. This patient was missing 2.5 hours of psychotherapy for the month of April 2019, 1 hours for the month of May 2019, .25 hours for the month of June 2019 and 1 hour for the month of July 2019. There was no documentation of client no shows or cancellations during those time periods.
Patient #6 was admitted on July 17, 2019 and was a current patient at the time of the inspection. This patient was missing 1.75 hour of psychotherapy for the month of August 2019 and 1 hour for the month of October 2019. There was no documentation of client no shows or cancellations during those time periods.
Patient #7 was admitted on July 18, 2019 and was a current patient at the time of the inspection. This patient was missing 1 hour of psychotherapy for the month of August 2019. There was no documentation of client no shows or cancellations during those time periods.
Patient #9 was admitted on March 6, 2019 and was a current patient at the time of the inspection. This patient was missing .5 hours of psychotherapy in the month of September 2019. There was no documentation of client no shows or cancellations during those time periods.
Patient #12 was admitted on July 18, 2018 and was a current patient at the time of the inspection. This patient was missing .5 hours of psychotherapy for the month of October 2019. There was no documentation of client no shows or cancellations during those time periods.
Patient #13 was admitted on October 9, 2018 and was discharged on February 20, 2019. This patient was missing 1 hour of psychotherapy of the month of November 2018, 1 hour for the month of December 2018 and 1.5 hours for the month of January 2019.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Clinic Director and Lead counselor are responsible for ensuring compliance with psychotherapy services. The Clinic Director reviewed the requirements for counseling services with all counselors on 12/02/19. As of 12/23/2019 each counselor will run their Direct Services Analysis reports in SMART and turn into the Clinic Director. Additionally the Clinic Director will run the report monthly and send results to the Director of Quality and Compliance with a plan of action for overall results below the benchmark of 96%. The Clinic Director and Lead Counselor will review the reports in individual and group supervision. Ongoing non-compliance in meeting the Direct Services requirement will be addressed by the Clinic Director individually utilizing the Employee Improvement Plan process.
Patients that missed counseling will be held to meet with a member of the clinical team prior to medicating to address issues of counseling non-compliance. Continued issues of counseling non-compliance after multiple intervention attempts will be brought to the team for consideration of an Administrative Medically Supervised Withdrawal. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, it was determined that the program failed document transferring a patient's file to another narcotic treatment program that included, admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, current status of the patient, and the written consent of the patient.
Patient #13 was admitted on October 9, 2018 and was transferred to another narcotic treatment program on February 20, 2019. There was no documentation that this patient's file was transferred to the receiving narcotic treatment program.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Clinic Director and Lead Counselor will review policy 7.1.14 which addresses the procedures for Transfer Patients. To monitor compliance in this area the Clinic Director or designee will conduct a Quality Record review on all discharge records including patient transfers. During the quality record review of all transferred patients the reviewer will ensure that there is documentation in the patient record that the patients transfer documents including admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, current status of the patient, and the written consent of the patient was sent to the receiving Program. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, it was determined that the program failed to document a discharge summary in 1 out of 14 records reviewed.
Patient # 4 was admitted on April 4, 2019 and was discharged on September 26, 2019. A discharge summary was not documented in this patient's record.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Clinic Director and Lead Counselor will review the policy for completing Discharge Summaries during the next Group Supervision which is scheduled for 01/08/2020. To monitor compliance in this area the Clinic Director or designee will conduct a monthly Quality Record review on all discharge records and will address deficiencies concerning Discharge Summaries as needed. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, it was determined that the program failed to document follow-up information in 2 out of 14 records reviewed.
Patient # 4 was admitted on April 4, 2019 and was discharged on September 26, 2019. Follow-up information was not documented in this patient's record.
Patient # 5 was admitted on April 16, 2019 and was discharged on September 6, 2019. Follow-up information was not documented in this patient's record.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Clinic Director and Lead Counselor will review the policy for completing Discharge follow ups during the next Group Supervision which is scheduled for 01/08/2020. To monitor compliance in this area the Clinic Director or designee will conduct a monthly Quality Record review on all discharge records and will address deficiencies concerning Discharge follow ups as needed. |
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
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, it was determined that the program failed to document treatment plan updates in compliance with the facilities written procedures for the management of treatment/rehabilitation services for clients in 4 out of 14 records reviewed.
Patient # 4 was admitted on April 4, 2019 and was discharged on September 26, 2019. A preliminary treatment plan was completed on April 4, 2019. A comprehensive treatment plan was to be completed no later than May 4, 2019 and a treatment plan update was to be completed no later than July 4, 2019. The comprehensive treatment plan was completed on August 7, 2019 and the treatment plan update was completed on August 12, 2019.
Patient #5 was admitted on April 16, 2019 and was discharged September 6, 2019. A preliminary treatment plan was completed on April 16, 2019. A comprehensive treatment plan was to be completed no later than May 16, 2019 and a treatment plan update was to be completed no later than July 16, 2019. The comprehensive treatment plan was completed on July 18, 2019 and the treatment plan update was completed on July 31, 2019.
Patient #8 was admitted on August 8, 2017 and was a current patient at the time of the inspection. A treatment plan for this patient was completed on November 26, 2018 and a treatment plan update was due no later than January 26, 2019; however, the next treatment plan update was completed on February 12, 2019. Additionally, a treatment plan was completed on March 8, 2019 and a treatment plan update was due no later than May 8, 2019; however, a treatment plan update was completed on June 13, 2019.
Patient #12 was admitted on July 18, 2018 and was a current patient at the time of the inspection. A treatment plan update was completed on January 30, 2019 and another treatment plan update was due no later than March 30, 2019; however, the next treatment plan update was completed on April 15, 2019. Additionally, the treatment plan update proceeding the April 15, 2019 update was due no later than June 15, 2019; however, the next treatment plan update was completed on July 5, 2019.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Clinic Director reviewed the requirements for treatment planning with all counselors on 12/18/19. As of 12/18/2019 each counselor will run their Services Due by type report for treatment plans weekly and turn into the Clinic Director for review. Additionally the Clinic Director will run the report monthly and send the results to the Director of Quality and Compliance with a plan of action for overall results below the benchmark of 98%. The Clinic Director and Lead Counselor will review the reports in individual and group supervision. Ongoing non-compliance in completing treatment plans timely will be addressed by the Clinic Director individually utilizing the Employee Improvement Plan process. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
During a review of the policy and procedure manual on November 21-22, 2019, the program failed to develop and implement policies and procedures to respond to the following unusual incidents:
-Inappropriate behavior by a patient causing disruption to the narcotic treatment program
-Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
-Drug related hospitalization of a patient.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The CTC Director will work
with the Director of Quality and
Compliance to develop a policy
to address how the facility will
respond to the following: 1.)
inappropriate behavior by a
patient causing disruption to the
narcotic treatment program, 2.)
Incident with potential for
negative community reaction or
which the facility director
believes may lead to community
concern. 3.) Drug related
hospitalization of a patient. The
policy will be developed by
1/31/2020. The CTC Director
will review all policy revisions
during the February 2020 All
Staff Meeting. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
During a licensing inspection conducted on November 21, 2019 through November 22, 2019, the project ' s policy and procedure manual did not address that a narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following the occurrence of the specific unusual incidents including the following:
-Complaints of patient abuse (physical, verbal, sexual and emotional).
-Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
-Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
-Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
-Drug related hospitalization of a patient.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Clinic Director will work with the Director of Quality and Compliance to revise the Unusual incident policy (3.4) to clarify that reporting of unusual incidents to external agencies is to be in compliance with State and Federal confidentiality laws and appropriate corrective action plan for an unusual incident, when indicated.The revision will be completed by 1/31/2020. The Clinic Director will review all policy revisions during the February 2020 All Staff Meeting. |