INITIAL COMMENTS
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This report is a result of an on-site licensure renewal, provisional license follow-up and methadone monitoring inspection conducted on October 25-27, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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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 personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #6 was hired as a counselor on September 8, 2021 and was still in that position at the time of the inspection. The employee was due to have both communicable disease trainings by September 8, 2022; however, both were not completed at the time of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 01/01/2022, all newly hired staff will complete HIV/AIDS and TB/STD training within the first year of hire, in accordance with State regulation 704.11(c)(1). The Office Manager will monitor all training requirements on a quarterly basis and report updates to the CTC Director via a quarterly training report.
Employee #6 has completed the HIV/ADIS training. As of 11/15/2022, there are no available seats for the required TB/STD trainings in the Northeast Region. When a training becomes available, prior to the end of 2022, Employee #6 will be registered to attend, or will complete this training via an on-line module.
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709.29 (a) LICENSURE Retention of client records
§ 709.29. Retention of client records.
(a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
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Observations
During the on-site inspection, the facility failed to have patient records readily accessible as the wait time to gain access for the Department staff was three hours and 20 minutes.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The request for the creation of unique credentials to the EHR Database for regulatory or other authorized parties to conduct quality and compliance record reviews has been submitted for approval (11/23/2022); thereby eliminating the delay in gaining access to the EHR Database during an unannounced site visit.
This request would provide 'standing-access' for regulatory or other authorized parties (as per regulation or contract agreement(s)) unique logon credentials to the EHR database.
Such is proposed to be approved and established by 12/5/2022. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of patient records, the facility failed to notify patients that reasons for removing sections shall be documented in the record in four out of four applicable records.
Patient #3 was admitted on December 8, 2021 and was still active at the time of the inspection.
Patient #4 was admitted on January 27, 2022 and discharged on July 13, 2022.
Patient #5 was admitted on January 5, 2022 and was still active at the time of the inspection.
Patient #6 was admitted on May 2, 2022 and discharged on October 6, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will work with the Director of Quality and Compliance to revise the Patient Rights to state that "The CTC Director may temporarily remove portions of the records prior to the inspection by the patient if the Director determines that the information may be detrimental if presented to the patient. Reasons for removing sections shall be documented in the record."
Dunmore has such policy in place (1.2.1) and we will continue to adhere to such policy in accordance with the DDAP standards. We will be sure to review policies with the auditor on site. All patients are provided with a copy of this policy as evidenced by their signing of the Patient Rights acknowledgement form at admission. Patients are also provided with a copy in their patient handbook which is also acknowledged on the "Patient Orientation" form. Additionally, the Patient Rights is posted in the lobby according to DDAP standards.
The CTC Director will review this upcoming policy revision during December 16th, 2022 all Staff Meeting. To allow for the revision to occur at the corporate level, the projected completed date for this correction is 01/31/2023. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to document an emergency contact in two out of nine records reviewed.
Patient #2 was admitted on June 8, 2018 and discharged on June 27, 2022.
Patient #5 was admitted on January 5, 2022 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Dunmore CTC will review the admission process to ensure all patients provide an emergency contact, including name, relationship to the patient, and contact number in the case of a medical emergency. Such will be added to the Counselor End of Day Checklist and reviewed with the staff member and the Clinical Supervisor to ensure any and all admission on that day have completed this process. An additional review will be conducted by the office manager, on a weekly basis, for all Pt. records admitted that week to ensure that emergency contact information is present. This information will be presented during an all staff meeting on December 16th, 2022 making note of the need for compliance to such and the ongoing monitoring of same |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on observation of medication administration, the facility failed to follow their policy and Procedures manual in regard to administration of medication. Section 6.1.1 of the policy and procedures manual requires patients to speak to the nurse assuring that medication has not been diverted. Two patients were not asked to speak prior to leaving the dispensing
area.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Dispensing nurses will ensure that every patient speaks following ingesting their medication dose, prior to departing from the dispensary window.
The Charge Nurse will present this information to all dispensing nurses during every monthly nurse meeting, commencing on the meeting scheduled for November 29, 2022.
Charge Nurse will add additional unannounced visits into the dispensary during dosing times to monitor dispensing staff for continued compliance on a weekly basis commencing on the week of November 21, 2022.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on the review of patient records, the facility failed to provide 2.5 hours of psychotherapy per month, one hour of which shall be individual psychotherapy, during the patient's first two years in three out of five applicable records.
Patient #1 was admitted on May 24, 2021 and was still active at the time of the inspection. In August 2022, the patient received one hour of individual therapy with one no show documented. In September 2022, the patient received one hour of individual therapy and one hour of group therapy.
Patient #5 was admitted on January 5, 2022 and was still active at the time of the inspection. In July 2022, the patient received two hours of individual therapy.
Patient #9 was admitted on August 5, 2021 and was still active at the time of the inspection. The patient did not receive any therapy in August 2022. In September 2022, the client received 30 minutes of individual therapy.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All Dunmore CTC patients are informed of their 2.5 hour counseling requirement per month, during their first two years of treatment. The Clinic Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services for all patients within this narcotic treatment program. The Clinical Supervisor reviews this regulation with each clinical team member during weekly individual and group supervision. Each counselor will enter "no show counseling" notes into the EMR when a patient does not attend a scheduled individual or group session and progressive interventions will be taken with patients who are non-compliant with treatment hours. Continued issues of counseling non-compliance after multiple intervention attempts will be brought to the Multi-Disciplinary Team, every Tuesday, for consideration of an Administrative Discharge. The Clinical Supervisor and Counseling staff will monitor compliance of all patients counseling requirements during weekly individual supervision as well as internal quality record reviews. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to transfer patient files in one out of one applicable record.
Patient #7 was admitted on August 19, 2019 and discharged on May 4, 2022.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will review policy 7.1.14 which addresses the procedures for Transfer Patients. To monitor compliance in this area the Clinical Supervisor will conduct a Quality Record Review on all discharge records including patient transfers. During the quality record review of all transferred patients, the reviewer will ensure that there is documentation in the patient record of transfer documents including admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, current status of the patient, and the written consent of the patient was sent to the receiving Program. This information will be discussed during a scheduled all Staff Meeting on December 16th, 2022. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to notify the transferring narcotic treatment program of the admission of the patient in one out of two applicable records.
Patient #5 was admitted on January 5, 2022 and was still active at the time of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will review policy 7.1.14 which addresses the procedures for Transfer Patients. To monitor compliance in this area the Clinical Supervisor will conduct a Quality Record review on all admission records that include patient transfers into this facility. During the quality record review of all newly admitted patients, the reviewer will ensure that there is documentation in the patient record that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program. This information will be discussed during a scheduled all Staff Meeting on December 16th, 2022. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of patient records, the facility failed to update treatment plans at least every 60 days in three out of five applicable records.
Patient #3 was admitted on December 8, 2021 and was still active at the time of the inspection. A treatment plan was completed on April 4, 2022 with an update due on June 4, 2022; however, it was not completed until June 6, 2022.
Patient #5 was admitted on January 5, 2022 and was still active at the time of the inspection. A treatment plan was completed on April 6, 2022 with an update due on June 6, 2022; however, it was not completed until June 10, 2022. In addition, a treatment plan was completed on August 8, 2022 with an update due on October 8, 2022; however, it was not completed until October 22, 2022.
Patient #9 was admitted on August 5, 2021 and was still active at the time of the inspection. A treatment plan was completed on July 19, 2022 with an update due on September 19, 2022; however, there was no documentation of an update being completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinic Director and Clinical Supervisor reviewed regulation 709.92(b) and the failure to comply with this regulation. A detailed review of patient charts are conducted on a weekly basis to ensure that clinical staff are completing necessary paperwork and documentation in a timely manner. The continued utilization of the EMR will ensure that all documentation is met within allotted time frames necessary to meet this regulation. All clinical staff will be required to complete internal audits of patient electronic records on a weekly basis. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of patient records, the facility failed to ensure that the patients received counseling services according to their individual comprehensive treatment plan in three out of six applicable records reviewed.
Patient #1 was admitted on May 24, 2021 and was still active at the time of the inspection. A treatment plan dated July 20, 2022 indicated 2.5 hours per month of therapy. In August 2022, the patient received 60 minutes of therapy with one no show documented. In September 2022, the patient received two hours of therapy.
Patient #5 was admitted on January 5, 2022 and was still active at the time of the inspection. A treatment plan dated June 10, 2022 indicated group and individual sessions per month. In July 2022, the client did not receive any group sessions.
Patient #9 was admitted on August 5, 2021 and was still active at the time of the inspection. A treatment plan dated July 19, 2022 indicated one hour of individual and an additional hour of either group or individual therapy. In August 2022, the client did not receive any therapy. In September 2022, the client received 30 minutes of individual therapy.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All Dunmore CTC patients are informed of the minimum 2.5 hour counseling requirement per month, during their first two years of treatment and 1 hour monthly minimum for those meeting regulation 01-14. The Clinic Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services for all patients within this narcotic treatment program, including that of goals, objectives, and interventions listed within the treatment plan. The Clinical Supervisor will review all treatment plans for an individualized hourly counseling requirement, that may be over that of the 2.5 hour regulation, for each patient - dependent upon patient compliance in treatment at the time of the current treatment plan.
The Clinical Supervisor will review this regulation with each clinical team member during weekly individual and group supervision. Each counselor will enter "no show counseling" notes into the EMR when a patient does not attend a scheduled individual or group session and progressive interventions will be taken with patients who are non-compliant with their treatment hours. Continued issues of counseling non-compliance after multiple intervention attempts will be brought to the weekly Multi-Disciplinary Team for consideration of an Administrative Discharge. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of patient records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for patients to receive an average of 2.5 hours of psychotherapy per month during the patient's first two years were submitted and approved by the Department for the October 13, 2016, November 16, 2017, November 15, 2018, November 19, 2019, November 13, 202, November 16, 2021 and March 24, 2022.
A plan of correction for not providing treatment services according to the patient's individualized treatment plan were submitted and approved by the Department for the November 16, 201 and March 24, 2022.
A plan of correction for not updating treatment plans within the regulatory timeframe were submitted and approved by the Department for the November 16, 201 and March 24, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Dunmore CTC will identify issues with proposed plans of correction as they present and formulate protocols to ensure that repeat citations are avoided in the future. The current plans of correction for this audit period will be closely monitored for compliance to each regulation noted to be deficient.
Counseling Requirements: If a patient does not meet the minimum counseling requirement during the month, including failure to adhere to their signed treatment plan, the reason for such will be documented in the patient file. Each counselor will enter "no show counseling" notes into the EMR when a patient does not attend a scheduled individual or group session. Counselors will continue to attempt to contact patients who are not meeting the minimum monthly counseling requirement immediately following a missed appointment, or after 4 weeks have passed without a clinical session. Patients who continue to refuse to meet minimum counseling requirements are placed on a Treatment Contract. A treatment team meeting is be held to review therapeutic interventions and strategies to increase session attendance. Approved interventions are incorporated into a Treatment Contract that is presented to and signed by the patient. CTC staff will determine, when a non-compliant patient may be eligible for Administrative Discharge due to counseling non-compliance. This decision will be made at the multi-disciplinary treatment team meeting, with agreement of the CTC physician, and the patient must be placed on an appropriate administrative detoxification schedule.
Treatment Plan Updates: The Clinical Supervisor will internally review all new and interim patient charts to ensure that clinical staff are completing necessary paperwork and documentation in a timely manner. The continued utilization of the EMR will ensure that all documentation is met within allotted time frames necessary to meet this regulation. All clinical staff will be required to complete internal audits of patient electronic records on a weekly basis.
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