INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 8, 2009 by staff from the Division of Drug and Alcohol Program Licensure. 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 and a plan of correction is due on November 5, 2009.
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Plan of Correction
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709.22(e)(3) 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:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on the review of administrative documentation which included the facility's annual report, the facility failed to disclose the names of the board of directors in the annual report.
The findings include:
On October 6, 2009 the annual report was reviewed. The facility failed to include a statement in the annual report disclosing the names of the officers, directors, and principal shareholders.
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Plan of Correction
The annual report will be amended to include a statement disclosing the names of officers, directors, and principle shareholders. Amendment completed 10/23/2009 by Program Director. This information will be included in future annual reports to be completed by the Program Director. |
709.28(c)(2) 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. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the information listed on the consent to release information forms permitting releases of information to the funding sources exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b).
The findings include:
Ten client records were reviewed on October 8, 2009. In six out of ten client records reviewed the facility exceeded the limitations on the type and amount of information that can be released, imposed at 4 Pa Code Subsection 255.5 (b).
In client record # 1 the facility disclosed methadone dosage information, discharge summary, psychosocial evaluation, prescription verification, medical evaluation and HIV/AIDS information to the funding source, which exceeded the limitations imposed at 4 Pa Code Subsection 255.5 (b).
In client record # 5 the facility disclosed methadone dose, discharge summary, psychosocial evaluation, prescription verification, medical evaluation, HIV/AIDS information and labwork to the funding source, which exceeded the limitations imposed at 4 Pa Code Subsection 255.5 (b).
In client record # 6 the facility disclosed methadone dose, psychosocial evaluation and medical evaluation to the funding source, which exceeded the limitations imposed at 4 Pa Code Subsection 255.5 (b).
In client record # 7 the facility disclosed information pertaining to methadone dose, labwork and medical evaluation to the funding source, which exceeded the limitations imposed at 4 Pa Code Subsection 255.5 (b).
In client record # 8 the facility disclosed information pertaining to methadone dose, lab work, psychosocial evaluation, prescription verification, medical evaluation and HIV/ AIDS information to the funding source, which exceeded the limitations imposed at 4 Pa Code Subsection 255.5 (b).
In client record # 10 the facility disclosed methadone dose, discharge summary, psychosocial evaluation, prescription verification, and medical evaluation to the funding source, which exceeded the limitations imposed at 4 Pa Code Subsection 255.5 (b).
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Plan of Correction
Training has been provided to staff on the proper completion of releases and what is permitted to be released under 4 Pa Code Subsection 255.5 (b) by the clinical director on 10/21/2009 in group supervision.
Releases will be reviewed in quarterly chart audits conduted by the clinical director to ensure compliance on an ongoing basis. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of the client records it was determined that the facility failed to complete comprehensive treatment plans within the timeframe stated in the policy and procedure manual.
The findings include:
On October 8, 2009 ten client records were reviewed. The facility failed to document timely comprehensive treatment plans in six of ten client records. According to the facility policy and procedure manual the comprehensive individualized treatment plans are due within 30 days of the preliminary treatment plan. The facility documented late comprehensive treatment plans in client records # 1, 3, 4, 6, 8, and 9. The findings are as follows:
The comprehensive treatment plan was due 5/2/2009 in record #1. The facility completed the comprehensive treatment plan on 5/12/2009.
The comprehensive treatment plan was due 5/7/2009 in record # 3. The facility completed the comprehensive treatment plan on 5/12/2009.
The comprehensive treatment plan was due 4/17/2009 in record # 4. The facility completed the comprehensive treatment plan on 4/26/2009.
The comprehensive treatment plan was due on 6/28/2009 in record # 6. The facility completed the comprehensive treatment plan on 8/10/2009.
The comprehensive treatment plan was due on 1/30/2009 in record # 8. The facility completed the comprehensive treatment plan on 2/12/2009.
The comprehensive treatment plan was due on 1/16/2009 in record # 9. The facility completed the comprehensive treatment plan on 1/23/2009.
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Plan of Correction
Timely treatment plan completion will be addressed and monitored with counselors in individual and bi-monthly group supervision by the Clinical Director.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records the facility failed to document case consultations within the guidelines of the facilities policy and procedure manual. According to the company policy and procedure manual case consultations will be completed at least quarterly. Documentation of case consultations was either not documented or was documented late in 4 of 10 client records.
The findings include:
On October 8, 2009 ten client records were reviewed. In two out of ten records the facility failed to document case consultations.
Record # 4 required a second case consultation by 9/17/2009. The facility had failed to document this case consultation as of October 8, 2009.
In Record # 10 a case consultation was due by 3/18/2009. The facility failed to document a case consultation for this record as of October 8, 2009.
Two out of ten case consultations were not timely. In records # 3 and 8 the case consultations were documented late by the facility.
In record # 3 the case consultation was due by 7/7/2009 and the facility did not complete a case consultation until 7/24/2009.
In record # 8 the case consultation was due on 3/30/2009 and the facility did not complete a case consultation until 6/19/2009.
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Plan of Correction
Case consults will be reviewed and monitored for timelinesss with counselors in individual and bi-monthly group supervision by the Clinical Director on an ongoing basis. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on review of the client records on October 8, 2009, the facility failed to document completed discharge summaries in four of five client records.
The findings include:
Ten client records were reviewed. Discharge Summaries were required in five client records. The discharge summaries in four out of five client records were incomplete. One out of five records were late.
The facility failed to document the reason the client was in treatment in records # 6, 8, 9, and 10.
Record # 10 was discharged on 4/11/2009. The discharge summary was due within 7 days of discharge. The facility failed to document a discharge summary until 5/4/2009.
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Plan of Correction
The discharge summary form was revised to include the reason for treatment byt the Clinical Director.
The timeliness of discharge summaries will be monitored for completion in individual and group supervision with counselors by the Clinical Director on an ongoing basis to ensure completion within the 7 day timeframe. |