INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the October 6, 2009 and October 7, 2009 licensure renewal inspection. The follow-up inspection was conducted on April 29, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Habit OPCO, Inc. - Allentown 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 May 24, 2010.
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Plan of Correction
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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.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of the fire extinguisher upon employment in one of two personnel records.
The findings include:
Four personnel records were reviewed. Two personnel record were required to include documentation of fire extinguisher training. The facility failed to document the completion of fire extinguisher training within the first week of employment in personnel record # 3.
Employee # 3 was hired on December 8, 2008. The training was to be provided and documented upon employment. The training was not documented until January 7, 2009, which was beyond the first week of employment.
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Plan of Correction
The Program Director will review the relevant regulations with all staff at the next general staff meeting on June 2, 2010. The Program Director met with the Office Manager, who is responsible for maintaining personnel records, to review the regulations and program policies individually. The Office Manager will develop and utilize a checklist for personnel records, to include all the required documentation. This checklist will be utilized when creating a new employee file.
The Program Director will review the personnel records of any new staff hired for the rest of 2010 to ensure compliance. The Program Director and Office Manager will conduct biannual audits of the personnel files to ensure compliance. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in two of two personnel records.
The findings include:
Four personnel records were reviewed. Two personnel records were required to include documentation that personnel on all shifts were trained to perform assigned tasks during emergencies. The facility failed to document the completion of emergency training prior to assigning shifts to employee # 3.
Employee # 3 was hired on December 8, 2008. The training was documented on January 7, 2009, which was after the employee had been assigned to work shifts.
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Plan of Correction
The Program Director will review the relevant regulations with all staff at the next general staff meeting on June 2, 2010. The Program Director met with the Office Manager, who is responsible for maintaining personnel records, to review the regulations and program policies individually. The Office Manager will develop and utilize a checklist for personnel records, to include all the required documentation. This checklist will be utilized when creating a new employee file. the Program Director also supplied the Office Manager with the proper form to be included in all personnel files.
The Program Director will review the personnel records of any new staff hired for the rest of 2010 to ensure compliance. The Program Director and Office Manager will conduct biannual audits of the personnel files to ensure compliance.
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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 review of the administrative documentation the facility failed to disclose the names of the members 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.
This is a repeat citation. The facility failed to follow their plan of correction that was submitted to the October 6 and 7, 2009 licensure inspection. Please submit a new plan of correction.
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Plan of Correction
The Addendum has been written. A copy has been placed in the Policy & Procedure Manual which is kept in the Program Director's office. An additional copy of the Addendum is kept with the Annual Report, filed in the Program Director's office. |
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:
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Observations
Based on the review of employee personnel records the facility failed to have a job description included in one of four records reviewed.
The findings include:
Four employee personnel records were reviewed on April 29, 2010. One of four records reviewed failed to have a signed job description. Employee record # 4 was hired on 3/1/2010 and as of the date of the inspection the facility failed to have a signed job description in the employee personnel record.
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Plan of Correction
The job description in question was signed and placed in the employee file on May 3, 2010. The Program Director met with the Office Manager, who is responsible for maintaining the personnel records, as well as with the Clinical Director and the Nurse Manager, who are responsible for the orientation of new staff. The Program Director reviewed the relevant regulations and the program policies pertaining to signed job descriptions.
The Program Director will follow up by reviewing the personnel records of all staff hired for the rest of 2010, to ensure compliance. In addition, the Office Manager or designee will meet with all newly hired staff on the first day of employment to ensure that the job description is reviewed and signed. Then, utilizing the checklist that has been developed, the Office Manager will make sure that the signed job description is included in the employee file. The Program Director and Office Manager will conduct audits of personnel files biannually to ensure compliance. |
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 and/ or probation officers exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b) and the facility failed to indicate what specific information would be disclosed.
The findings include:
Fifteen client records were reviewed on April 29, 2010. In six out of fifteen 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). Additionally, in five out of fifteen records, the facility failed to indicate what specific information was going to be disclosed to a person or agency.
The consent to release information forms that were completed in client records # 1, 2, 5, and 7 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 records # 11 and 12 the facility disclosed information pertaining to Methadone/Suboxone Dose to the probation officer. This information exceeds the limitations imposed at 4 Pa. Code Subsection 255.5(b).
In client record # 1, there was a consent for a county agency signed by the client that failed to indicate what information was going to be released to this agency.
In client record # 11 the facility failed to indicate what they were going to release to the Managed Care Organization. The consent only indicated the purpose of the release as being "obtaining health insurance coverage."
In client records # 6 and 13 there were releases of information for the client's emergency contact that failed to indicate what was going to be released to this person.
In client record #10 the facility failed to indicate what they were going to release to the Managed Care Organization. The consent only indicated the purpose of the release as being "coordination of services."
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Plan of Correction
The Clinical Director, Program Director and Nurse Manager have distributed "dummy" examples of correctly completed Consents to Release information to all staff. The "dummy" examples covered various categories of Consents. The issue of correct completion of releases was reviewed at the general staff meeting on May 6, 2010, with "dummy" examples reviewed individually, and an additional in-service training to be held in the near future will include this on the agenda.
Beginning May 10, 2010 and continuing through June 1, 2010, all staff who complete a Consent to Release Information will print out the release and it will be reviewed and cosigned by the respective supervisor as follows: the Clinical Director will cosign releases completed by the counseling staff; the Program Director will cosign releases completed by the administrative staff; the Nurse Manager will cosign releases completed by the nursing staff. Any incorrect releases will be rewritten.
For the month of June, 2010, the Clinical Director, Nurse Manager and Program Director will review all releases completed in the SMART system software and any further incorrect releases will be rewritten. |
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 April 29, 2010, the facility failed to document completed discharge summaries in five of ten client records and failed to include services offered in four of ten records.
The findings include:
Ten client records were reviewed. Discharge Summaries were required in ten client records. The discharge summaries in five out of ten client records were not complete and four out of ten records failed to include the services offered.
In client records # 1, 7, 8 and 15 the facility failed to document the services offered to the client on the discharge summary.
In client record # 2 the facility failed to document the reasons for treatment, response for treatment and and the client's status at discharge.
In client record #3, the client was discharged on 3/16/2010. The discharge summary was due by 3/23/2010. As of the date of the follow-up inspection the facility failed to document a discharge summary for this client record.
In client record # 4, the client was discharged on 2/8/2010. The discharge summary was due by 2/15/2010. As of the date of the follow-up inspection the facility failed to document a discharge summary for this client record.
In client record # 9, the client was discharged on 2/16/2010. The discharge summary was due by 2/23/2010. As of the date of the follow-up inspection the facility failed to document a discharge summary for this client record.
In client record # 10, the client was discharged on 3/23/2010. The discharge summary was due by 3/30/2010. As of the date of the follow-up inspection the facility failed to document a discharge summary for this client record.
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Plan of Correction
The regulations and policy on completion of Discharge Summaries was reviewed at the general staff meeting on May 6, 2010. In addition the policy will be reviewed at group supervision with all counselors during the month of May. The Clinical Director and Senior Counselor will monitor all discharges for the next six months, and review in individual supervision, to ensure that Discharge Summaries are completed within the deadline.
The Discharge Summary form has been revised to include space for indicating all 'services offered'. The counselors have been instructed on the proper use of the revised form.
The Clinical Director, Program Director, and Medical Director will monitor and review the forms as they are submitted for signature at the time of discharge. |
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 April 29, 2010, the facility failed to document follow up information where required in two of ten client records.
The findings include:
Fifteen client records were reviewed. Ten client records required documentation of attempts to follow-up on the client after discharge. The facility failed to document follow-up attempts in two client records where required. According to the facility policy, follow-ups will be conducted for clients who are referred out of the program within one week. Additionally, they will document, in the client progress notes, follow-up attempts within sixty days after discharge by phone. The facility did not document follow-up information in client records # 1. and 8.
Client # 1 was discharged on 2/5/10 and transferred to another treatment program. Follow-up was required by 2/12/2010. No follow-up was documented by the program within one week to determine if the client made his/her appointment. As of the date of this inspection no follow-up information was documented in this client record.
Client # 8 was discharged on 1/21/2010. No follow-up attempt was documented in the client record as of the date of this inspection.
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Plan of Correction
The regulations and policy on completion of follow up information was reviewed at the general staff meeting on May 6, 2010. In addition the policy will be reviewed at group supervision with all counselors during the month of May. The Clinical Director and Senior Counselor will monitor all discharges for the next six months, and review in individual supervision, to ensure that follow up contacts are completed within the deadline.
For those patients who cannot be reached by telephone, a form letter has been created to be mailed to the address on record in the patient's chart after discharge. The counselors have been instructed on the proper use of the form letter, which will be sent along with the list of resources that is handed out at admission.
The Clinical Director will monitor and review the completion of follow up contacts when they are due by utilizing the program software in order to generate the relevant report. This will be discussed in individual supervision weekly for three months, and then monthly for three months.
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