INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 6 & 7, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of seven personnel records on October 6, 2009 the facility failed to ensure that each counselor met the qualifications for the position they hold in one of four records.
Findings:
In personnel record #7, the counselor did not meet the qualifications for the position of counselor based on a Bachelor of Arts in Criminal Justice. In addition, the transcripts were reviewed by the Division and were found not to meet the educational component for the position of counselor.
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Plan of Correction
The employee in personnel record #7 has been changed to a Counselor Assistant effective 10-28-2009. Job Description reviewed and signed by the Clinical Director with the employee.
The Clinical Director will review resumes and credentials of potential employees with the Program Director to ensure the candidate meets the standards set for counseling staff prior to hire. The Program Director will be responsible to ensure that clinical staff have either a CAC or a qualifying degree. |
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 review of the administrative documentation 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, where applicable.
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Plan of Correction
The Annual Report will be amended to include a statment disclosing the names of the 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 Program Director. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on observation during the physical plant tour the facility failed to have the fee schedule posted in a prominent place.
The findings include:
On October 6, 2009, during the inspection of the physical plant, the facility failed to have the fee schedule posted in a prominent place.
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Plan of Correction
October 6, 2009, the fee schedule was re-posted on the patient bullitin board. Postings will be monitored on a monthly basis and re-posted if necessary 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 consent to release information forms 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 7, 2009. In six out of ten records reviewed the information to be released listed on the consent to release information forms by the facility exceeded the limitations imposed at 4 Pa code, Subsection 255.5 (b).
The consent to release information forms that were completed in client records # 1, 2, 4, and 5 included a medical evaluation as some of the information that would be released to the funding source. The content of the medical evaluation exceeded the limitations imposed at 4 Pa code, Subsection 255.5 (b).
In client record # 3 the facility disclosed information pertaining to Methadone/Suboxone Dose, Discharge Summary, Prescription Verification, Medical Evaluation, Psychosocial Evaluation, and HIV/AIDS information to the funding source. This information exceeds the limitations imposed at 4 Pa. Code Subsection 255.5(b).
In client record # 10 the facility disclosed information pertaining to the Psychosocial Evaluation, Medical Evaluation, Discharge Summary, and Methadone/Suboxone Dose to the funding source. This information exceeds the limitations imposed at 4 Pa. Code Subsection 255.5(b).
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Plan of Correction
Training was provided to staff on the proper completion of releases and what is permitted to be released under 4 PA code, Subsection 255.5 (b) on 10/21/2009 in group supervision of clinicians by the Clinical Director. Releases will be reviewed in quarterly chart audits by the Clinical Director to ensure compliance. |
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 7, 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.
In client record #7 the facility failed to document the reasons for treatment and the client's status at discharge.
In client record # 8 the facility failed to document the reasons for treatment and the client's status at discharge.
In client records # 9 and 10 the facility failed to document the reasons for treatment, the client's response to treatment and the client's status at discharge.
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Plan of Correction
The Discharge summary form was revised to include and document reasons for treatment, client status at discharge, client response to treatment. Discharge summaries will be reviewed and signed by the Clinical Director, and Program Director to ensure that all discharge summaries are complete on an ongoing basis. |
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.
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Observations
Based on the review of client records on October 7, 2009, the facility failed to document follow up information where required in two of four client records.
The findings include:
Ten records were reviewed. Four client records required documentation of attempts to follow-up on the client after discharge. The facility failed to document follow-up attempts in two of four records where required. The facility did not document follow-up information in client records # 7 and 10.
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Plan of Correction
Follow -up will be done and documented on clients #7 and 10 by 11/1/2009 by the counselor.
Counselors will complete and document follow up contacts in the timeframe required on an onoging basis. This will be monitored monthly in individual supervision by the Clinical Director. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on observation during the physical plant tour, the facility failed to have the hours of operation posted conspicuously to the general public.
The findings include:
On October 6, 2009, during the inspection of the physical plant, the facility failed to have the hours of operation posted conspicuously for the general public. According to staff interview with the facility director, the hours of operation had formerly been posted and someone must have removed them prior to the inspection.
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Plan of Correction
October 6, 2009 the hours of operation were re-posted on the front window for public viewing. This posting will be monitored on a monthly basis and re-posted as needed by the Program Director. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on observation during the physical plant tour the facility failed to have the emergency telephone number posted conspicuously to the general public.
The findings include:
On October 6, 2009 during the inspection of the physical plant the facility failed to have the emergency phone number posted conspicuously to the general public. According to staff interview with the facility director, the emergency number had formerly been posted and someone must have removed it prior to the inspection.
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Plan of Correction
October 6, 2009 the emergency number was re-posted on the front window for public viewing. This posting will be monitored on a monthly basis and re-posted as needed by the Program Director. |