INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 3- 4, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit OPCO- 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 "Staffing Requirements Facility Summary Reports" (SRFSR) for three of the facilities in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.
The findings include:
The SRFSR for the three facilities reviewed that make up part of the the project list a total of 11 full-time counselors and 3 full-time lead counselors. The total of the hours per week provided to the project by counselors equates to 14 FTE counselor positions within the project.
The SRFSR for the three facilities reviewed within the project revealed that no employees were listed as a full-time clinical supervisor. The SRFSR listed each of the three facility having a part-time clinical supervisors as facility directors; therefore they are unable to provide full-time clinical supervision. A full-time equivalency of 14 counselors would require a minimum of 1 full-time clinical supervisors and one part-time clinical supervisor within the project.
|
Plan of Correction
Habit OPCO will change the title and responsibilities of two of the projects current Facility Directors to Clinical Directors (by December 17, 2012). The new responsibilities ensure that the Clinical Directors will work as Clinical Supervisors as defined in PA regulations for Drug and Alcohol Treatment Facilities. This change will ensure that Habit OPCO has an appropriate amount of Clinical Supervision for sixteen (16) clinicians in the Pennsylvania Project. Habit OPCO currently employs fifteen (15) clinicians. Additionally, to ensure that this does not recur, Habit OPCO will begin recruiting for a third (3rd) Clinical Director for the project, with an anticipated start date no later than February 2013. This will ensure that Habit has sufficient Clinical Supervision for twenty-four (24) clinicians. By December 17, 2012, Habit OPCO will appoint a Facility Director to oversee all four facilities. Notification of this change (for electronic plans of correction) will be submitted to the Pennsylvania Department of Drug and Alcohol Programs no later than December 21, 2012. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
|
Observations
Based on a review of agency policy and procedures, staffing requirements facility summary report, and personnel records, the facility did not document staff training needs assessments in four of six records reviewed.
The findings include:
Based on a review of agency policy and procedures, staffing requirements facility summary report on October 3, 2012, and a review of personnel records, the facility failed to document staff training needs assessments. According to the policy and procedures, staff will complete a questionnaire each December and return them to the program director. According to the facility's policy, the training year is based on the calendar year of January through December. Seven personnel records were reviewed on October 3, 2012. The facility failed to document needs assessments in employee records # 2, 5, 6, and 7.
Employee # 2 was hired January 3, 2012. The facility failed to document an assessment of the staff training needs.
Employee # 5 was hired on August 20, 2012. The facility failed to document an assessment of the staff training needs.
Employee # 6 was hired August 6, 2012. The facility failed to document an assessment of the staff training needs.
Employee # 7 was hired August 13, 2012. The facility failed to document an assessment of the staff training needs.
This finding was discussed with the facility director on October 3, 2012 and was not disputed.
|
Plan of Correction
The Program Director will ensure that all staff on site receives a copy of the staff training questionnaire during the monthly staff meeting on November 26, 2012. Staff will be required to complete this document and have it back to the Program Director and/or their designee by close of business on Monday, December 3, 2012.
The Program Director will review each of these with each staff member and/or their immediate supervisors.
From this review the Program Director will develop with each staff an annual individual training plan for the next calendar year. Once plans are finalized, they will be provided to each staff member and recorded in their personnel records.
All newly hired staff will be expected to complete the training needs questionnaire during their first week of employment. This will be reviewed with their immediate supervisor and finalized with training recommendations. Once completed, a copy will be provided to staff and filed accordingly in thier personnel chart.
On-going reviews will continue to be conducted during individual supervision sessions with each staff member throughout the year.
Training specific focus during supervision sessions will be to ensure compliance with the annual individualized plans created. Supervision sessions will occur with the Program Director and/or the staff member immediate supervisor with whom they finalized the plan.
These end of year time frame, utilizing November and December, will remain as the standard for completing subsequent plans moving into the following year. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
|
Observations
Based on a review of the agency policy and procedures, the facility failed to document an overall plan for addressing training needs, as required by regulation.
The findings include:
On October 1, 2012, the agency policy and procedures were reviewed. Per the agency policy and procedures, the facility director will collect training data and he/she will formulate a comprehensive training plan by the end of January each year. The regulation requires an overall plan for addressing training needs to be completed as a component of a staff development program. According to the facility's policy, the training year is based on the calendar year (January 2012 - December 2012). The facility failed to document the completion of an overall training plan for the 2012 training year.
This finding was discussed with the facility director and was not disputed.
|
Plan of Correction
The Program Director will ensure that all staff on site receives a copy of the staff training questionnaire during the monthly staff meeting on November 26, 2012. Staff will be required to complete this document and have it back to the Program Director and/or their designee by close of business on Monday, December 3, 2012.
The Program Director will review each of the submitted training questionnaires along with supervisory staff on site.
From this review the Program Director will develop and overall facility training plan for the Pottstown location and submit the same to the Project Director by close of business on Januray 18, 2013.
Additionally, the Director of PA Operations has initiated a comprehensive training needs assessment via all PA programs in order to ascertain the training needs and interests of all staff within the Project. This, along with the individual training plan for the Pottstown location will be utilized to solidify the overall training plan for HOI-Pottstown.
The Program Director will review and present the overall training plan to all staff when it is available; anticipated to do so at the January 2013 Monthly staff meeting.
Additional on-going reviews will continue to be conducted during individual supervision sessions with each staff member throughout the year. On-going supervisory sessions will spend some time focusing on training specific items to ensure compliance with the comprehensive training plan as well as the individual annual training plans developed at the beginning of the year and/or at the time of new staff being hired. |
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.
|
Observations
Based on a review of the staffing requirements facility summary report and personnel records, the facility failed to provide documentation of individual training plans in five of seven records reviewed.
The findings include:
The staffing requirements facility summary report and personnel records were reviewed on October 3, 2012. Seven employee records were reviewed. The facility failed to document a individual training plan in employee records # 1 , 2, 5, 6, and 7. According to the staffing requirements facility summary report, the facility failed to document a training plan for five of seven support staff members.
An interview with the facility director, confirmed that the training plans for 2012 were not completed on staff.
|
Plan of Correction
The Program Director will ensure that all staff on site receives a copy of the staff training questionnaire during the monthly staff meeting on November 26, 2012.
Staff will be required to complete this document and have it back to the Program Director and/or thier immedicate supervisor by close of business on Monday, December 3, 2012.
The Program Director and supervisory staff will review each of these. Following this review, supervisory staff will meet with their respective staff members and review the plans submitted. Staff will be provide discourse as to the approptiateness of each submission and supervisors will add final training plan recommendations for the upcoming year.
The final plans will be provided to the staff member and filed in their personnel record for ongoing review as to progress being made.
This process will be implemented with each new hire within the first 30 days of employment. This will ensure that all staff have in place an annual training plan for the current year.
All personnel records will reflect individual training plans for the 2013 calendar training year. These plans will be documented and filed no later than January 4, 2013.
|
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on the review of personnel records, the facility failed to document fire extinguisher training upon staff employment.
The findings include:
Seven personnel records were reviewed on October 3, 2012 to verify that staff had been instructed in the use of a fire extinguisher upon employment. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records # 2, 4 5, 6, and 7.
Employee # 2 was hired on 1/3/2012. Fire extinguisher training was due within seven days of hire. The facility failed to documented fire extinguisher training in this personnel record.
Employee # 4 was hired on 9/10/2012. Fire extinguisher training was due within seven days of hire. The facility failed to documented fire extinguisher training in this personnel record.
Employee # 5 was hired on 8/20/2012. Fire extinguisher training was due within seven days of hire. The facility failed to documented fire extinguisher training in this personnel record.
Employee # 6 was hired on 8/6/2012. Fire extinguisher training was due within seven days of hire. The facility failed to documented fire extinguisher training in this personnel record.
Employee # 7 was hired on 8/13/2012. Fire extinguisher training was due within seven days of hire. The facility failed to documented fire extinguisher training in this personnel record.
This finding was confirmed by the facility director and was not disputed.
|
Plan of Correction
Prior to this audit, the Program/Director identified and scheduled a fire extinguisher training for all staff with the Montgomery County Fire Marshall. This training was completed on Friday October 5, 2012 where all staff on site received this training.
Pursuant to our policies and procedures all newly hired staff will receive appropriate fire extinguisher training within the first seven (7) days of their employment with HOI-Pottstown. Documentation to the same will be present in their personnel file to support their successful completion to the same.
Additionally, under 'Other' categories on HOI Corporate New Hire packets, Fire Extinguisher training will be noted and identified as completed within the time frames denoted via this policy. Submission of a request to edit the HOI Corporate New Hire packets to list Fire Extinguisher Training within a new hires first week of employment. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
|
Observations
Based on a review of the annual report, the facility failed to include a financial statement of income and expenses in the 2011 annual report.
The findings include:
The 2011 annual report was reviewed on October 3, 2012. The annual report failed to include a financial statement of income and expenses. This finding was discussed with the facility director and was not disputed.
This is a repeat citation from the October 13, 2011 licensing inspection.
|
Plan of Correction
The Program Director will ensure that all subsequent annual reports include the following:
- A statement disclosing the names of officers, directors and principle share holders;
- Financial statements reflecting income and expenses for the program;
- A listing of activities and accomplishments for the preceeding year.
Additionally, notification of this reports availabilty via the HOI website will be presented for audit notification. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
|
Observations
Based on the review of the facility's administrative documentation, the facility failed to document project goals and objectives which include time frames and available resources.
The finding include:
The facility's administrative documentation was reviewed on October 3, 2012. The facility director provided goals and objectives for 2012, however, they failed to include time frames and available resources. The goals and objectives also failed to indicate whether they were based on a calendar year or fiscal year.
This finding was reviewed with the facility director and was not disputed.
|
Plan of Correction
The Program Director will ensure to update all program goals and objectives to include specific time frames and available resources that will aid in the achievement of identified goals and objectives.
Time frames will be delineated on a quarterly basis dependent upon the goal to be achieved.
With regard to the Project goals and objectives the Program Director will ensure to include them within the annual report for the facility as appropriate and ensure that time frames and available resources are identified as well where appropriate; to include responsible parties to the same.
Aforementioned information will be drafted into the annual report to be completed by the end of January 2013
|
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
|
Observations
Based on a review of personnel records, the facility failed to document written job descriptions which contained the employee's and supervisor's dated signatures in four of seven personnel record, as required by regulation.
The findings include:
Seven personnel records were reviewed on October 3, 2012. The facility failed to obtain the required documentation of a signed job description in personnel records # 4, 5, 6, and 7.
Employee # 4 was hired on September 10, 2012 as a counselor. There was no documentation of a signed job description in personnel record # 4.
Employee # 5 was hired on August 20, 2012 as a counselor. There was no documentation of a signed job description in personnel record # 5.
Employee # 6 was hired on August 6, 2012 as a counselor. There was no documentation of a signed job description in personnel record # 6.
Employee # 7 was hired on August 13, 2012 as a counselor. There was no documentation of a signed job description in personnel record # 7.
The facility director was interviewed on October 3, 2012. It was confirmed that there was no documentation of a job description in these personnel records.
|
Plan of Correction
Since the exit interview from this audit, any personnel file that did not have a signed Job Description/Performance Evaluation has been signed and added.
The continued use of the Job Description/Performance Evaluation will continue on site. The Program Director will ensure that these are signed on the first day of work for any and all new hires and that the existing Orientation packet reflects the same. Administrative staff have been trained in the completion of this process as of this drafting.
The "Job Description" statement has been and will be highlighted at the heading of this document to ensure verification that this document has been presented to all new hires as the specific job description for their position and that staff's signature is indicative of their signing acknowledgement to the same.
A review of all personnel records by the Program Director will ensure ongoing compliance to this requirement. |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
|
Observations
Based on the review of patient records, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation in one of two patient records.
The findings include:
Eleven patient records were reviewed October 3-4, 2012. Two patient records were reviewed for involuntary, or administrative discharge. One patient record contained documentation of the patient being discharged for reasons other than those listed by regulation.
Patient # 1 was admitted on March 9, 2012 and discharged on July 19, 2012. The record included documentation that the patient was given an immediate discharge for diverting his medication. The patient was not afforded a 7 day detoxification at the facility or referred to another facility. There was a termination letter included in the record, however, there was no documentation showing that the patient was provided a copy of the termination notice. The patient was not afforded the opportunity to appeal the decision for termination.
|
Plan of Correction
The Program/Clinical Director will ensure to provide consideration for appropriate medically supervised tapers as defined in regulations. With the case in point, this author did implement an emergency taper due to the diversion of medication and, as noted in 715.21(I)(ii) '...distributed a controlled substance in or around the narcotic treatment program...'as was confirmed by the patient in question.
The Program/Clinical Director will ensure that supporting documentation is more readily available to support any and all actions with regard to taper actions.
The Program/Clinical Director will ensure that continued compliance is met for all emergency and non-emergency tapers and that the latter are provided appropriate, medically supervised, taper regiments as denoted within the regulations.
|
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
Based on a review of patient records, the facility failed to document the lengths and patterns related to the patient's progression of drug and alcohol use in six of six records.
The findings were:
Eleven patient records were reviewed on October 3-4, 2012. Six records were reviewed for required documentation of drug and alcohol history that included lengths and patterns related to the patient's progression of use. The facility failed to document the lengths and patterns related to the patient's progression of use in patient records # 5, 7, 8, 9, 10, and 11.
This finding was discussed with the facility director and was not disputed.
|
Plan of Correction
When clinical staff are completing the bio-psychosocial the progression of use with the lengths of patterns of use/abuse is listed within the table on page 4. These bio-psychosocials are reviewed and signed off as completed by the Program/Clinical Director.
As of this audit, Clinical staff will be provided additional training to ensure that individualized patterns and progressions of patient use/abuse is also recorded in the clinicians progress notations to the Intake and within the body of the interpretavie summary as it relates to the clinicians overview of the specific case.
All new staff will recieve the same training as part of their clinical orientation and supervisory sessions.
On-going chart audits, conducted by the Program/Clinical Director and lead clinician and/or other supervisory staff will be conducted to ensure ongoing compliance of documentation being completed accurately, filed and readily available.
These audits will be conducted as per policy and will be enhanced with the addition of a Lead Clinician on site.
|
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
|
Observations
Based on a review of patient records, the facility failed to document a physical examination that included the patient's general appearance in ten of ten records reviewed.
The findings include:
Eleven patient records were reviewed on October 3-4, 2012. The facility failed to document general appearances on the physical examination forms in patient records # 1, 2, 3, 5, 6, 7, 8, 9, and 10.
|
Plan of Correction
As of the exit interview from this audit, the Program Director has met with both the Medical Director and the Nurse Manager and has identified the location of the physical examinations notation of the patients' general appearance.
This author has noted to both the Medical Director and to the Nurse Manager that the notation of the patients' general appearance needs to be listed within the first line of the MD's intake notification.
This will be included and noted accordingly beginning in November 2012.
Ongoing reviews of medical notations listing these additions will be conducted by the Program Director and Nurse Manager on a routine basis to ensure compliance.
The Program Director will notify the PA Director of Operations and the Corporate Medical Director as to the need to ensure compliance amongst all PA Physicians during their ongoing operations and orientations to the Project. This notification will occur at the time of approval to this Corrective Action.
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of patient records, the facility failed to document a psychosocial evaluation in two of six records as required.
The findings include:
Eleven patient records were reviewed on October 3- 4, 2012. Six patient records were reviewed for a psychosocial evaluation as required by the regulations. The facility's policy and procedures required the psychosocial evaluations to be documented within thirty days of admission. The facility failed to document psychosocial evaluations in patient records # 6 and 9.
Patient # 6 was admitted on July 23, 2012. The psychosocial evaluation was due by August 23, 2012. The facility failed to document a psychosocial evaluation in this patient record as of the date of the inspection.
Patient # 9 was admitted on July 11, 2012. The psychosocial evaluation was due by August 11, 2012. The facility failed to document a psychosocial evaluation in this patient record as of the date of the inspection.
This finding was discussed with the facility director and was not disputed.
|
Plan of Correction
In addition to staffing changes made on site in Pottstown, intake and subsequent filing procedures have also been adjusted. This will provide more effective and efficient documentation filing for psychosocials that were completed yet not present in the file at the time of this audit.
Clinical staff will ensure that any and all psychosocial evaluations containing drug & alcohol history, including lengths and patterns of progression, are physically filed within 48 hours of their completion, and within ten (10) days from the point of intake.
The Program Director will hold further trainings with existing clinical staff to ensure compliance to this end. These trainings will be conducted in clinical group supervision sessions during the months of November and December 2012.
On-going monthly reviews of the same will occur during clinical group and individual supervisory sessions moving forward. This will also be presented to all new clinical staff during their orientation period as well as during ongoing supervisory sessions.
The Program/Clinical Director will continue to review the completion of the psychosocial evaluations for authorization, along with the completion of progress notations presenting detailed data of progression and patters of abuse in the clinicians narrative.
Additional measures to this end include the bio-psychosocial being updated and added within the electronic charting system, SMART, used on site. Once this MIS/IT update is completed it will provide for the electronic completion of the psychosocial evaluation, thereby ensuring the documents presence within the patient record.
On-going chart audits will be conducted to ensure ongoing compliance of documentation being filed and readily available. These audits will be conducted as per policy and will be enhanced with the addition of a Lead Clinician on site.
|
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
|
Observations
Based on a review of patient records, the facility failed to document follow-up information as per agency policy in two of two patient records.
The findings include:
Five discharged patient records were reviewed on October 4, 2012. Two of the five discharged patients had been discharged for the amount of time required for follow-up contact. Per agency policy, follow up contact will be completed within 30 days of discharge for clients not referred to other programs. Follow-up was not documented within 30 days of discharge in patient records # 1 and 4.
Patient #1 was admitted to outpatient treatment on March 9, 2012 and discharged on July 19, 2012. A follow-up contact was due to be completed by August 19, 2012. There was no follow-up contact documented in client record # 1.
Patient # 4 was admitted to outpatient treatment on August 15, 2011 and discharged on June 23, 2012. A follow-up contact was due to be completed by July 23, 2012. There was no follow-up contact documented in client record # 4.
|
Plan of Correction
As of the time of the exit interview for this audit, the Program/Clinical Director has addressed the follow-up contact information gathering process as noted within our policies and procedures and as identified via the regulations.
Staff has been informed of this protocol and the need for consistent contacts to be made. The use of alternative time tables, such as Outlook reminders, has been presented and recommended by the Program Director during Group Supervision session which occurred on October 5, 2012.
Additionally, this issue was presented during the Monthly staff meeting on Friday, October 26, 2012. Follow up contacts and the form utilized for the same was reviewed and presented, along with the identification of alternative staff other than the primary clinician who may complete this task to ensure compliance and effective clinical care to those whom we have served.
The Program Director will ensure compliance to this regulation by providing routine, monthly, checks to any and all patients discharged within the prior 30 days to the date of the chart review. Follow up notations will be made to this end under Administrative Intervention notes. Once a lead clinician is identified, they will also be available to provide follow up services to the follow-up contacts for patients and the accountability measures to the same.
|