INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and inspection conducted for the approval to use a narcotic agent, specifically methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on September 16-18, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Habit OPCO, Inc. was found not to be in compliance with the applicable chapters of 4 PA Code and 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 staff training documentation, the Staffing Requirements Facility Summary Report (SRFSR), and discussion with facility staff, the facility failed to ensure all staff requiring a minimum of 6 hours training of HIV/AIDS and at least 4 hours training of tuberculosis, sexually transmitted diseases and other health related topics obtained the training within the required timeframes.
The findings include:
A review of the SRFSR, completed by the facility, and training files on September 16-17, 2014 identified five staff that were required to have completed the HIV/AIDS and TB/STD trainings prior to the date of this inspection. Three staff members did not have the required trainings documented at the time of the inspection.
Staff member # 4 was hired in October 2012 and was to have received these trainings by October 2013. There was no documentation the staff person had received these mandatory trainings at the time of the inspection.
Staff member # 5 was hired in April 2013 and was to have received these trainings by April 2014. There was no documentation the staff person had received these mandatory trainings at the time of the inspection.
Staff member # 13 was hired in March 2012 and was to have received these trainings by March 2014. There was no documentation the staff person had received these mandatory trainings at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will ensure that all existing, and new hires, complete HIV/AIDS along with the TB/STD trainings by February 2, 2015.
The Facility Director will identify a party who can complete this training on site for all staff by the date noted.
Hiring manger(s) will ensure that all new hires provide copies of completed trainings within this category. Those who have not completed these trainings will have them listed on their Initial Individual Training plan to be completed within the first year. Use of the DDAP Trainings system will be reviewed with new hires in need of these training(s) in order to identify dates for completion.
All new hire candidates who have completed this training will be required to provide evidence to the same which will be filed in their personnel file on site.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of staff training records, the Staffing Facility Summary Report (SRFSR) and discussion with facility staff, the facility failed to ensure the facility director received the required number of training hours during the past training year.
The findings were:
A review of the Staffing Requirements Facility Summary Report completed by the facility director prior to the onsite inspection and a review of staff training records on September 18, 2014 showed that the facility director did not obtain any training hours for the prior training year. A discussion with the facility director confirmed there were no training hours acquired for the training year under review.
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 Facility Director completes the required number of training hours during the course of each year.
This will be reviewed by the Project Director at the onset of the calendar year when the Annual Individual Training plan is completed and submitted for the Facility Director. This will be monitored throughout the year to ensure compliance and to avoid a repeat deficiency. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of staff training records, the Staffing Requirements Facility Summary Report and discussion with facility staff, the facility failed to ensure all the counselor's received the required number of training hours during the past training year.
The findings were:
A review of the Staffing Requirements Facility Summary Report completed by the facility director prior to the onsite inspection, and staff training records on September 18, 2014 revealed that two of three counselor's did not complete a minimum of 25 training hours for the prior training year.
Staff member # 3 was required to have completed 25 training hours during the previous training year. The staff person provided documentation of 12 training hours for that time period.
Staff member # 4 was required to have completed 25 training hours during the previous training year. The staff person provided documentation of 8 training hours for that time period.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will work with all staff to ensure that the Annual Individual Training Plans that are developed at the beginning of each calendar year are actualized by the respective staff member. The Facility Director will develop a Training Tracking system that will be maintained by the Administrative Asst. and or their designee, that will afford the opportunity to review staff completed trainings throughout the calendar year to ensure compliance to this regulation. This effort will remain ongoing to ensure this is not a repeat deficiency for the Dunmore Location. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR), administrative documentation and discussion with facility staff, the facility failed to maintain counselor full time equivalent (FTE) caseloads to no more than 35 to 1.
The findings include:
The SRFSR reviewed prior to the onsite inspection, and administrative documentation that included counselor caseloads reviewed and discussed with staff September 16, 2014 revealed that five counseling caseloads exceeded 35:1.
Counselor # 3 had an FTE caseload of 36:1
Counselor # 4 had an FTE caseload of 36:1
Counselor # 5 had an FTE caseload of 37:1
Counselor # 6 had an FTE caseload of 38:1
Counselor # 7 had an FTE caseload of 41:1
These findings were reviewed with facility staff during the inspection.
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Plan of Correction
At the time of this audit, HOI-Dunmore was understaffed based on ratio's due to the resignation of a clinical team member. During the audit period, the Facility Director was actively engaged in the process of scheduling and completing interviews for a replacement candidate.
Subsequent to the audit dates in question, a new clinician has been identified and offered the position on site in Dunmore. This candidate has accepted the position and is scheduled to begin employment on Monday, November 3, 2014. This hire will place HOI-Dunmore back into compliance with this regulation.
Any and all staffing adjustments that directly impact regulatory ratios will be reviewed in advance, if possible, of their occurrence. When feasible the following steps will be initiated: 1.New hires will be sought out to overlap the exiting staff member,
2. Exceptions filed for increased staffing ratios pending the new hire process.
These actions will be reviewed and initiated by all hiring mangers on site in Dunmore. |
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, the facility failed to make the 2013 annual report available to the public.
The findings include:
On September 16, 2014 the facility's administrative documentation was reviewed. The facility was required to make an annual report available to the public.
The 2013 annual report was provided and reviewed during the inspection; however, the facility failed to verify how the annual report was made available to the public.
The findings were reviewed with the 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 made to be 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 to CRC Behavioral Health, the access to the HOI website was sense 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 repeat 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 Dunmore's annual report is available for review. |
709.28(c) 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:
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client that adhered to 4 Pa. Code 255 in nine of fourteen client records reviewed.
The findings included:
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Nineteen client records were reviewed September 16-18, 2014. Fourteen client records were reviewed for documentation of an informed and voluntary consent from the client prior to the disclosure of information.
Client record # 3 contained a release of information for a funding source allowing the release of the psychosocial evaluation of the client, "utilization review" information, discharge summary, last methadone dose, and prescription verification, exceeding the five points outlined for release in 4 PA Code 255.5.
Client record # 4 contained a release of information for a funding source allowing the release of the psychosocial evaluation of the client, "utilization review" information, discharge summary, last methadone dose, and prescription verification, exceeding the five points outlined for release in 4 PA Code 255.5.
Client record # 6 contained a release of information for a funding source allowing the release of the psychosocial evaluation of the client, "utilization review" information, discharge summary, last methadone dose, and prescription verification, exceeding the five points outlined for release in 4 PA Code 255.5.
Client record # 7 contained a release of information for a funding source allowing the release of the psychosocial evaluation of the client, "utilization review" information, discharge summary, last methadone dose, and prescription verification, exceeding the five points outlined for release in 4 PA Code 255.5.
Client record # 12 contained a release of information for a funding source allowing the release of the psychosocial evaluation of the client, "utilization review" information, discharge summary, last methadone dose, and prescription verification, exceeding the five points outlined for release in 4 PA Code 255.5.
Client record # 13 contained a release of information for a funding source allowing the release of the psychosocial evaluation of the client, "utilization review" information, discharge summary, last methadone dose, and prescription verification, exceeding the five points outlined for release in 4 PA Code 255.5.
Client record # 14 contained a release of information for a funding source allowing the release of the psychosocial evaluation of the client, "utilization review" information, discharge summary, last methadone dose, "clinical rationale for treatment" and prescription verification, exceeding the five points outlined for release in 4 PA Code 255.5.
Client record # 16 contained a release of information for a funding source allowing the release of the psychosocial evaluation of the client, "utilization review" information, discharge summary, last methadone dose, and prescription verification, exceeding the five points outlined for release in 4 PA Code 255.5.
Client record # 18 contained a release of information for a funding source allowing the release of the psychosocial evaluation of the client, "utilization review" information, discharge summary, last methadone dose, and prescription verification, exceeding the five points outlined for release in 4 PA Code 255.5. Also, this client record contained documentation of a signed consent for a medical facility that failed to identify what specific information was to be released.
This is a repeat citation. The facility was previously cited for noncompliance with this standard during the licensure inspections conducted on 10/11/2013 and 10/12/2012.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director will ensure that the dated release template that remains in SMART (EHR), which does request the noted information to ascertain a 'out of network' agreement with the MA Provider, be removed by the IT Department. This will not allow for this release to be available for signing. Additionally, a review of the process and removal of said release will be conducted with the Admission(s) team to ensure they are made aware of the lack of need for this release in that HOI-Dunmore is now in network with said funding source. A review of all cases will be conducted by the Administrative Asst. and/or their designee to ensure that any such releases that remain on file are 'revoked' accordingly. It is noted that with some of the cases cited under this deficiency the release authorization in question was already revoked and/or expired. In that they cannot be physically removed from the electronic health record it is requested that the status of the release be taken into account during any future audits. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of patient records, the facility failed to ensure that verbal medication orders were signed within 24 hours by the prescribing physician in three of thirteen patient records reviewed.
The findings include:
Thirteen patient records containing documentation of verbal orders were reviewed on September 16-18, 2014 to ensure that the orders were put in writing and signed within 24 hours by the prescribing physician. Four patient records contained verbal orders that were signed more than 24 hours after being issued.
Patient # 13 was admitted April 2, 2014. A verbal order was issued by the physician June 3, 2014. The verbal order was signed by the physician June 5, 2014, more than 24 hours after being issued.
Patient # 18 was admitted July 22, 2014. A verbal order was issued by the physician July 25, 2014. The verbal order was signed by the physician July 29, 2014, more than 24 hours after being issued.
Patient # 19 was admitted January 28, 2014. There were multiple verbal orders that were issued and not signed within 24 hours by the physician.
1- Verbal order issued 2/3/14 and signed 2/5/14
2- Verbal order issued 2/9/14 and signed 2/14/14
3- Verbal order issued 3/28/14 and signed 3/30/14
4- Verbal order issued 2/3/14 and signed 2/5/14
5- Verbal order issued 5/31/14 and signed 6/3/14
6- Verbal order issued 6/3/14 and signed 6/5/14
7- Verbal order issued 7/6/14 and signed 7/8/14
8- Verbal order issued 8/23/14 and signed 8/26/14
The findings were reviewed with facility staff during the inspection.
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Plan of Correction
The Facility Director will continue to work with the Medical Director to ensure the timely signing off of medical verbal orders.
The Facility Director, even at the time of the drafting of this POC, is working with CRC IT department to re-format a laptop for the Medical Director. This laptop will ensure the Medical Director has access to the Dunmore Pt. database. This will allow for any verbal orders provided, by the Physician on day's when they may not be in the office, to be signed off on in a 24 hour parameter.
Additionally, the Facility Director has scheduled and will provide the Medical Director with a training on the use and access via the laptop on Thursday, November 6, 2014;. This training to ensure compliance to this regulation and to prevent any future citing's under this category. |
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."
This is a repeat citation. The facility was previously cited for noncompliance with this standard during the 11/6/2013 inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will direct the point at which the Patient handbook is to be re-drafted. This specific area has been a focus of this re-drafting effort and, coupled with the recent acquisition, will certainly put this effort back on the top of the 'to do' list for all HOI locations.
The Facility Director will meet with the Project Director on Wed., October 29, 2014, via the weekly CTC Director's teleconference meeting, to present the Patient handbook re-draft project to ascertain what a time frame may look like for this project. And to inquire as to any assistance that may be provided by this author to expedite this process.
A review of DDAP Regulations will be used in the effort when redrafting said sections of the Patient Handbook to ensure a thorough and accurate revision is completed and will correct any future deficiencies under this category.
A review of the existing Pt. handbook will be reviewed and inserts added to reflect the noted adjustments pending final draft of the new Pt. handbook. As of the aforementioned meeting date of October 29, it is noted that HOI locations will be adopting the CRC patient handbook with state specific updates.
The Facility Director will ensure that edited updates are provided to all existing Pt.'s and future Pt.'s with the insert addendum's to be added. Additionally, with the marquee on site, the Facility Director will create a slide to reflect the adjustments that will be posted on the waiting room lobby marquee. Thereby all patients will have an additional outlet by which to review the edits to the Pt. handbook. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to complete the annual physical with a re-evaluation by the physician in two of three patient records reviewed.
The findings include:
Nineteen patient records were reviewed September 16-18, 2014. Three patients were to have an annual physical with a re-evaluation documented in their records. The facility failed to document an annual physical with a re-evaluation by the physician in two patient records, # 10 and # 16.
Patient # 10 was admitted May 1, 2013. The annual physical exam was completed on April 17, 2014, but did not include a re-evaluation by the physician.
Patient # 16 was admitted April 19, 2013. The annual physical exam was completed on April 17, 2014, but did not include a re-evaluation by the physician.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will meet with the Medical Director on Thursday, October 30th and will review the entire process related to the annual physical and re-evaluation of the patient in order to ascertain the medical necessity to continue with this level of care (MMTP).
Documentation processes will be reviewed to ensure the appropriate language is included in the annual physical notation completed by the MD to support their findings as to the patients re-evaluation for continued care needs.
All such documentation will be provided as required by the MD immediately! |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of the patient records, the facility failed to document the signature of the medical director on the annual evaluation in two of the three patient records reviewed.
The findings include:
Nineteen patient records were reviewed September 16-18, 2014. Three of the nineteen patient records were reviewed for an annual evaluation. Two of the three records failed to include the medical directors signature on the annual evaluation.
Patient # 10 was admitted to treatment on May 1, 2013. The annual evaluation was completed on May 2, 2014. The evaluation was not signed by the medical director as required.
Patient # 16 was admitted to treatment on April 19, 2013. The annual evaluation was completed late on June 9, 2014. The evaluation was not signed by the medical director as required.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will meet with the Medical Director on Thursday, October 30th and will review the necessity for the Medical Director to review and sign off on all clinical annual evaluations completed by the primary clinicians.
Prior to this meeting, this author will meet with the Senior Clinician to review and ensure that the process exists to provide ample notification to the Medical Director so that these actions are taken as denoted herein and that this is not a repeat citation for HOI-Dunmore.
The aforementioned meetings have occurred individually and are slated for further discussion/presentation during the November 20, 2014 mandatory Monthly Directors Meeting. |