INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection, and a complaint investigation conducted on September 9-11, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, the allegations made against Habit OPCO, Inc. - Allentown were unable to be substantiated. However, 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.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of employee training files, the facility failed to ensure staff persons shall receive at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum.
The findings include:
Four employee training files were reviewed on September 9, 2014, for documentation that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training.
Three counselors did not receive at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum within the first year of employment, specifically employee # 1, 3 and 5.
Employee # 1 was hired as a counselor on 4/16/12 and was required to receive 4 hours of TB/STD training by 4/16/13. There was no documentation of this training at the time of review on 9/9/14.
Employee # 3 was hired as a counselor on 9/19/11 and was required to receive 4 hours of TB/STD training by 9/19/12. There was no documentation of this training at the time of review on 9/9/14.
Employee # 5 was hired as a counselor on 12/3/12 and was required to receive 4 hours of TB/STD training by 12/31/13. There was no documentation of this training at the time of review on 9/9/14.
In addition, the facility documented 0 hours for TB/STD training for employee # 1 and 5 on the Staffing Requirements Facility Summary Report that was complete on 9/11/14.
The findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency. The facility was previously cited for noncompliance on October 24, 2013.
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Plan of Correction
The Program Director will meet with the Medical Director to schedule in- house HIV and Tuberculosis/Sexually Transmitted Diseases trainings. The content of the trainings will following the DDAP guidelines.All current employees will be be up-to -date on these trainings by December 31,2014, which is the end of our present training year. The traing dates will be in place by 11/1/2014.
New hires will register for DDAP HIV and Tuberculosis/ Sexually transmitted diseases within their first 60 days of employment.The dates of registration will be added as part of the new hire 60 day written evaluation, and will be confirmed by the Program Director prior to signing off on the evaluation to ensure compliance.
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure that counseling sessions cannot be heard outside the counseling room.
The findings include:
An on-site licensing inspection was conducted from 9/09/14 to 9/11/14. On 9/11/14 the licensing specialists could clearly hear the counseling session that was being conducted in the counseling room that was adjacent to the room where they were situated.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure compliance in keeping the privacy of counseling sessions, noise machines will be placed outside of each counseling office. The Program Director will randomly check machines while sessions are in progress to be sure the machines are being used. |
709.22(e) 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:
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Observations
Based on a review of administrative documentation, including the 2013 annual report, the governing body failed to verify that the annual report was made available to the public.
The findings include:
The administrative documentation was reviewed on September 9, 2014. The governing body failed to verify that the annual report was made available to the public.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that the Annual Report for the facility is publicly accessible. This has been completed in previous years by way of the Corporate Web site and listing of the overall Project Annual report.
Via the acquisition of HOI by CRC Behavioral Health, the access to the HOI website was since discontinued and therefore the annual reports unobtainable as of March 2014.
The Facility Director will seek direction from the Project Director as to the public posting of said annual reports moving forward under the new Corporate Design to ensure this is not a repeated deficiency. If the corporate design is similar, the facility Director will ensure that the posting is made via the CRC web page and print off a copy for review during the next audit cycle. If this is not the standard practice, the Facility Director will ensure that said notification is placed into the local media newspaper and a 'tear sheet' will be available for review from the dated paper.
Either way, the deficiency will be corrected and notification will be made available to the public that Allentown's annual report is available for review.
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a physical plant inspection, the facility failed to secure client records within a locked storage container.
The findings include:
A physical plant inspection was conducted on September 10, 2014. The facility failed to maintain client records within locked file cabinets. Three unlocked file cabinets were observed in the staff kitchen and pass through to the first floor group room.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To protect the confidentiality of stored patient charts,keys to filing cabinets will be held by Administrative Assistant. Clinicians will have to sign out keys when they want to access patient chart information.When returning the keys, they will have to sign stating the file cabinet has been locked.
Program Director and Administrative Assistant will regularly check file cabinets to ensure all confidential information is secure in a locked cabinet at all times. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a physical plant inspection, the facility failed to secure and maintain the confidentiality of all patient records.
The findings include:
A physical plant inspection was conducted on September 10, 2014. The facility failed to secure and maintain client records within locked file cabinets. Three unlocked file cabinets were observed in the staff kitchen and pass through to the first floor group room.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To protect the confidentiality of stored patient charts,keys to filing cabinets will be held by Administrative Assistant. Clinicians will have to sign out keys when they want to access patient chart information.When returning the keys, they will have to sign stating the file cabinet has been locked.
Program Director and Administrative Assistant will regularly check file cabinets to ensure all confidential information is secure in a locked cabinet at all times.
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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.
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Observations
Based on a review of the "Patient policies and Procedures Treatment Handbook," the facility failed to restrict their policy and procedure on involuntary terminations to those areas specified in the regulations.
The findings include:
A review of the patient handbook on September 10, 2014 revealed that patients were informed they could be terminated for reasons other that those specified by regulations.
According to the handbook documentation, patients could be involuntarily terminated for:
pg. 20 "Habit OPCO may terminate your treatment immediately, prior to a hearing and without benefit of a medically-supervised taper under the following conditions: Habit OPCO may issue you an emergency termination notice when the Program Director reasonably determines that your continued treatment in the program presents an immediate and substantial risk of physical harm to other patients, program staff or property, or the Medical Director reasonably determines that your continued treatment presents a serious documented medical risk. You still have the right to appeal this termination at both the program and state levels."
pg. 16 " LATE PAYMENTS - If you fall more than 7 days behind in your payments and do not request an acceptable repayment agreement, your treatment plan will be modified or updated to include your financial responsibility for paying for treatment if it is not already included. Failure to comply with the specifics of your treatment plan will result in a notice of intent to discharge, also known FINANCIAL DETOX.
LOSS OF INSURANCE - If at any point during treatment you lose your insurance coverage, you will be immediately notified of your change in status to private pay. You will be allowed 5 business days to have your insurance reinstated. If your insurance is not reinstated you will be responsible for payment on day 6. Failure to pay will result in the procedures described above."
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of PA Operations discussed the deficiency findings of regulation 715.21(1)(i-iv) with the Clinical Director.
The patient handbook in the PA clinics will be revised to include only regulatory reasons for discharge as outlined in regulation 715.21(1)(i-v). An addendum will be given to patients with the patient handbook informing them of the changes to reasons for involuntary discharge.
Regulation 715.21(1)(i-v) will be reviewed with staff during group supervision on November 21,2014 along with the procedure of implementing the addendum.
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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 a physical plant inspection, the facility failed to conspicuously display the hours of operation to the general public.
The findings include:
A physical plant inspection was conducted on September 10, 2014. The facility failed to display the project's hours of operation to the general public.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will post the facility hours of operation outside of all doors of the building for the general public.
HOI Allentowns monthy facility operations checklist, completed by our security associate, will include the inspection of posted hours of operation to ensure they are in good shape,visible,and legible.
The Program director will review the monthly facility operations checklist ensuring the posted hours of operation remain in compliance. |
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 a physical plant inspection, the facility failed to conspicuously display a telephone number to the general public for emergency purposes.
The findings include:
A physical plant inspection was conducted on September 10, 2014. The facility failed to display an emergency telephone number to the general public.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will place our 24 hour emergency phone number on the outside off all doors to ensure the general public can access help at any time.
HOI Allentowns monthy facility operations checklist, completed by our security associate, will include the inspection of the posted emergency telephone number to ensure it is in good shape,visible,and legible.
The Program director will review the monthly facility operations checklist ensuring the posted emergency phone number remains in compliance.
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