INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on November 17-18, 2021 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to document that the facility director met both the education and experiential qualifications for the position.
Employee #2 was hired on December 30, 2019 and promoted to facility director on November 15, 2020. The employee does not have a qualifying degree and has no documented program planning experience.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The staff member in question obtained their Associates Degree in 2010 and became a LPN in 2012. They began their career in Human Services and Pt. care in July of 2010 and their Nursing career in 2012 and have consistently maintained various levels of responsibility in the Human Services/Health Care Industry; including Nursing Management and Supervision since 2018, accumulating over a decade of professional Human Service experience to date.
The Regional Director will assume all Director responsibilities of this facility until such time as the staff member has successfully completed the appropriate level of training in concert with §704.5(c). A change of Director notification will be filed as early as Friday, February 4, 2022. Due to previously rejected POC's to §704.5(c) the corrective action date has been duly adjusted.
Pursuant to §704.5(c) the staff member has been set up with a training and supervision schedule as of January 1, 2022, which includes weekly direct supervision and mentoring that will be provided by the Regional Director. The staff member will attend to various training opportunities covering topics specific to SUD and program operations.
Effective 4 February 2022, additional corrective measures will be put into place.
A continual review of staff members accomplishments towards full compliance under §704.5(c) will be completed and provided during quarterly intervals to Licensure via email communications; unless otherwise specified.
A final review will be conducted and results of same submitted prior to the next audit period for the Facility.
As previously noted, an exception has been filed to §704.5(c) for consideration to this staff members education (Associates Degree in Applied Sciences, with a concentration in Health Arts with a Practical Nursing Emphasis), and near twenty years of professional experience in the health care setting with supervisory experience.
While awaiting a determination to the noted filed exception, the aforementioned plan of correction will be in place.
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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, the facility failed to ensure that employee #5 received at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #5 was hired as a counselor on May 6, 2020 and was due to have the communicable disease training no later than May 6, 2021. There was no documentation in the personnel file of the completion of the training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director and Clinical supervisor will ensure Employee is up to date with TB/STD, Communicable disease and other health related trainings by March 1 2022.
The CD will review with each manager and with all new hires the need to ensure TB/STD and communicable disease trainings are scheduled and completed within accordance to regulatory policy timelines. |
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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of patient records, the facility failed to document a complete consent to release information form in one out of seven patient records, as the form did not list what specific information could be released.
Patient #5 was admitted on August 24, 2021 and was still active at the time of the inspection. The consent form was dated August 23, 2021 to a government agency.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will review release of record consent forms in EMR system with all staff by 1/31/22.
All staff will have a release of records training by 1/31/22 to ensure all staff are compliant with completing release of information forms.
Both clinical and Administrative personnel will be required to review any/all new admissions and or newly submitted ROI's to ensure accuracy and compliance. Additionally, such will remain part of the clinical programs monthly chart review process.
ROI compliance will be reviewed quarterly, by the Clinic Director or their designee, during the monthly all staff meeting rotation(s).
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709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on the review of patient records, the facility failed to document a complete consent to release information form in one out of seven patient records, as the form did not list a purpose of disclosure.
Patient #7 was admitted on June 18, 2021 and was still active at the time of the inspection. The form was dated June 18, 2021 to an emergency contact.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director and Clinical Supervisor will review release of record consent forms in EMR system with all staff by 1/31/22.
All staff will have a release of records training by 1/31/22 to ensure all staff are compliant with completing release of information forms.
Both clinical and Administrative personnel will be required to review any/all new admissions and or newly submitted ROI's to ensure accuracy and compliance. Additionally, such will remain part of the clinical programs monthly chart review process.
ROI compliance will be reviewed quarterly, by the Clinic Director or their designee, during the monthly all staff meeting rotation(s).
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709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of patient records, the facility failed to document a complete consent to release information form in one out of seven records reviewed, as the form did not include a dated signature of the client.
Patient #1 was admitted on April 5, 2018 and discharged on August 10, 2021. Five consent forms dated April 5, 2021 were to a funding source, government agency, community resource, family member and a doctor. Another consent form dated August 3, 2021 was to a community resource. The release forms were signed and dated by a witness, but they were not signed by the patient.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinic Director will review this release of record consent form in EMR system with all staff by 1/31/22.
All staff will have a release of records training by 1/31/22 to ensure all staff are compliant with completing release of information forms, thoroughly.
Both clinical and Administrative personnel will be required to review any/all new admissions and or newly submitted ROI's to ensure accuracy and compliance. Additionally, such will remain part of the clinical programs monthly chart review process.
ROI compliance will be reviewed quarterly, by the Clinic Director or their designee, during the monthly all staff meeting rotation(s). |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of physician timesheets, the facility failed to provide at least one hour of physician time a week on site for every ten patients.
During the week of July 4-10, 2021, the patient census was 227. The facility was required to provide at least 22.7 physician hours. There were 16.5 hours documented.
During the week of September 26-October 2, 2021, the patient census was 231. The facility was required to provide at least 23.1 physician hours. There were 22.5 hours documented.
This is a repeat citation from the April 26, 2017, December 13, 2017, November 28, 2018, November 26, 2019 and November 6, 2020 annual licensing inspections.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director, in concert with the Regional Director, will ensure that the sufficient coverage is provided by the Program Physician, providing at least 1 hour per week onsite for every ten patients, along with the use of the mid-level practitioner adhering to the accepted ratio breakdown for same.
A Physician schedule has been developed as of 12/27/2021 and will be submitted to the medical staff monthly to ensure there is adequate coverage of PA/CRNP and MD per census requirements during all times.
The CTC Director will monitor the monthly calendar to ensure there is adequate coverage between MDs and PA/CRNP and, if warranted, will add additional practitioner(s) to the team as needed.
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715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review of physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census. The facility has been granted an exception request which permits the physician to provide one-fifth of the required hours with a certified registered nurse practitioner or physician's assistant providing the remaining four-fifths of the required hours.
During the week of August 8 - 14, 2021, the patient census was 228. The physician was required to provide one-fifth of the 22.8 hours, which equals to 4.56 hours. The physician only provided 3.5 hours.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director, in concert with the Regional Director, will ensure that the sufficient coverage is provided by the Program Physician, providing at least 1 hour per week onsite for every ten patients, along with the use of the mid-level practitioner adhering to the accepted ratio breakdown for same.
A Physician schedule has been developed as of 12/27/2021 and will be submitted to the medical staff monthly to ensure there is adequate coverage of PA/CRNP and MD per census requirements during all times.
The CTC Director will monitor the monthly calendar to ensure there is adequate coverage between MDs and PA/CRNP and, if warranted, will add additional practitioner(s) to the team as needed.
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715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on the observation of medication administration, the facility failed to properly verify the correct identity of a patient prior to administration of an agent. Section 6.1.1, #7d of the facility's policy and procedures manual states "patients will present at the dispensing window without hats or sunglasses. There was one observed occurrence where the patient was not asked to remove their hat prior to dosing.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director, Charge Nurse and Medical Director will ensure nursing staff is properly, identifying patients with hats and sunglasses, and instructing those individuals to remove such prior to dosing; as per 6.1.1 #7d facility's policy.
The Clinic director and Medical director will monitor compliance in this area by reviewing with nursing staff monthly, the first review occurring during the January 28, 2022 monthly staff meeting.
Additionally, the Admin. and Security personnel will be trained to identify such, along with the clinical team to ensure all are assisting and educating Pt.'s to same.
All to be reviewed during the January 28, 2022 staff meeting.
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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 direct observation of medication administration, the facility failed to ensure medication was properly administered by asking the patient to speak following dosing. One patient was observed not speaking prior to leaving the dosing area.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director and Medical director will ensure nursing staff is properly observing patients when ingesting the medication and speaking after ingesting medication according to 715.17.
The Clinic director and Medical director will monitor compliance in this area by reviewing with nursing staff by 1/31/22.
This will also be a focus of the January 28, 2022 staff meeting to ensure Pt.'s are educated and/or reminded of the importance of same.
As part of weekly supervision and monthly staff meetings, this will be discussed and reviewed, with random spot checks by the Charge Nurse to be completed throughout the month and reviewed with Dispensing personnel.
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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 and the date of the initial dose administered in one out of two applicable records.
Patient #7 was admitted on June 8, 2021 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 CTC Director and Clinical Supervisor will ensure all staff are compliant with transfer policies and procedures of clinic.
The CD will review transfer policy and procedure with all staff to ensure all transfer documentation is completed, previous treatment clinic is aware of transfer and all documentation is entered into patient chart according to policy. This will be reviewed with staff during the January 28, 2022 staff meeting.
Patient transfer confirmation will be monitored by the Clinic Director and/or Clinical Supervisor or designee to confirm transfer patients arrival and date of initial dosing on site; documenting same in the Pt. record.
This will be reviewed during the Monthly Staff meeting on Friday, January 28, 2021; and periodically thereafter during monthly staff meetings. |
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 the review of patient records, the facility failed to document a completed annual evaluation which included legal standing, financial management abilities and family and community supports in two out of three applicable records.
Patient #1 was admitted on April 5, 2018 and discharged on August 10, 2021. The annual clinical evaluation was completed on March 17, 2021.
Patient #6 was admitted on September 9, 2020 and was still active at the time of the inspection. The annual clinical evaluation was completed on September 20, 2021.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will ensure the Clinical Supervisor, medical and counseling team maintain strict monitoring to patient compliance and adherence to completing annual evaluations on start date of patient admission. Clinical supervisor, clinical and medical team will run monthly reports in Smart to ensure all patients annual evaluations are completed on the anniversary of the Pt.'s admission date.
This plan will be reviewed with all staff by January 31, 2022 with immediate and sustained implementation as of that date during regular clinical supervision sessions.
The clinical supervisor and a nurse team member will attend to a monthly meetings with the Clinic Director, part of which will provide updates as to the corrective measures being conducted and maintenance to same.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of patient records, the facility failed to document a complete psychosocial evaluation in three out of four applicable records.
Patient #3 was admitted on September 28, 2021 and was still active at the time of the inspection.
Patient #5 was admitted on August 24, 2021 and was still active at the time of the inspection.
Patient #7 was admitted on June 18, 2021 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
The CTC Director will ensure the Clinical Supervisor is strictly monitoring the counseling staff's compliance and adherence to psychosocial evaluations; including Pt. participation to same.
The clinical supervisor will continue with weekly review(s) of each counselor, to include the requirements for psychosocial evaluation documentation.
Reports in the Facility EHR [SMART] are run regularly and will be reviewed during each of these weekly supervision meetings, along with the Counselor End of Day Report Submission.
This plan will be reviewed with the clinical supervisor on Tuesday, January 18, 2022 with the expectation of such going into effect on that same date.
Adherence will continue to be reviewed by the Clinic Director during regularly scheduled, weekly supervision sessions.
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on the review of patient records, the facility failed to document proposed support services on the patient's individual treatment plan in four out of four applicable records.
Patient #2 was admitted on July 27, 2021 and was still active at the time of the inspection. The treatment plan was dated August 3, 2021.
Patient #3 was admitted on September 28, 2021 and was still active at the time of the inspection. The treatment plan was dated October 14, 2021.
Patient # 5 was admitted on August 24, 2021 and was still active at the time of the inspection. The treatment plan was dated September 8, 2021.
Patient #7 was admitted on June 18, 2021 and was still active at the time of the inspection. The treatment plan was dated July 20, 2021.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director and Clinical Supervisor will ensure the counseling team receive training on the necessity of including support services and type to all Pt. Tx plans on site; this training will be offered to all team members during the January 28, 2022 mandatory monthly staff meeting.
The clinical supervisor will monitor counseling staff compliance and adherence to documenting support services on the respective individual treatment plan(s) during weekly supervision, utilizing reports generated from the EHR [SMART] as evidence to same.
Progress and updates to same will be reviewed during the clinical supervisors' weekly supervision meetings with the Clinic Director.
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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 two out of six applicable records.
Patient #6 was admitted on September 9, 2020 and was still active at the time of the inspection. A treatment plan update was completed on April 20, 2021 with the next update due no later June 20, 2021; however, it was not completed until September 1, 2021.
Patient #7 was admitted on June 18, 2021 and was still active at the time of the inspection. A treatment plan update was completed on August 6, 2021 with the next update due no later than October 6, 2021; however, it was not completed until October 19, 2021.
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 Clinical Supervisor and team to ensure timely updates are documented to all patient individual treatment plans in accordance to §709.92(b).
The Clinic Director and clinical supervisor will review this with all counseling staff during the January 28, 022 staff meeting.
The clinical supervisor will monitor and aid with oversight to same during weekly supervision meetings with their team to ensure tx plans are updated every 60 days; utilizing reports from the CTC's EHR [SMART] to support same.
This plan will be reviewed with the clinical supervisor on Tuesday, January 18, 2022 and implemented immediately thereafter.
Progress and updates to same will be reviewed during the clinical supervisors' weekly supervision meetings with the Clinic Director.
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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 counseling services were provided according to the patient's individualized treatment plan in three out of seven records reviewed.
Patient #1 was admitted on April 5, 2018 and discharged on August 10, 2021. A treatment plan dated May 20, 2021 stated one hours of individual counseling per month. In June 2021, the patient received 30 minutes of individual counseling on June 28, 2021. There were no other documented sessions or no shows during that month.
Patient #3 was admitted on September 28, 2021 and was still active at the time of the inspection. A preliminary treatment plan dated September 28, 2021 indicated individual sessions every two weeks. A comprehensive treatment plan was completed on October 14, 2021 indicating 2.5 hours of counseling every month. In October 2021, there were no individual sessions and only one hour of group therapy on October 11, 2021.
Patient #4 was admitted on January 19, 2019 and was still active at the time of the inspection. A treatment plan dated July 23, 2021 indicated one hour per month individual counseling. In August, September, and October 2021 there were no documented individual sessions.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
It remains essential to ensure patients are adhering to the clinical parameters jointly established between them and their primary counselor.
During regularly scheduled supervision, the counselor will review with the clinical supervisor random treatment plans and gauge patient compliance to such, developing plans to ensure patient compliance to same.
A summary review of the various plans that may be uniquely devised for each patient, during individual supervision, will be shared with the counseling team during monthly group supervision sessions to aid in offering additional creative ways to address patient non-compliance.
Utilizing reports from SMART, review of patient expected clinical engagement will also be reviewed to ensure there is cohesiveness between patients expected level of service need(s) and what is reported on the patient individual treatment plan.
Certainly, amidst the current Pandemic (sars-cov-2) the use of telehealth services will aid in achieving compliance to 715.19(2).
This plan will be reviewed with the clinical supervisor on Tuesday, January 18, 2022 and rolled out to the counseling team that same day; with a review offered during the January 28, 2022 monthly staff meeting.
Proper documentation of patient no-shows or cancellations will be reviewed during weekly group supervision with the Clinical Supervisor, along with updates to Pt. Treatment plans in order to assist Pt. in gaining compliance.
Adherence to same will be reviewed by the Clinical Supervisor during individual and group supervision sessions.
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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 the review of physician timesheets, the facility failed to comply with plans of correction approved by the Department. A plan of correction was submitted to the Department for inspections occurring on November 6, 2020, November 26, 2019, November 28, 2028, December 13, 2017, and April 26, 2017, addressing the requirement to provide physician services at least one hour per week onsite for every ten patients.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Although there was not 'review' offered to this author during the licensing process, it is expected that all Clinic Directors are reviewing any and all previous Plans of Corrections (POC's) submitted to ensure adherence or, when needed, updates to previous Licensing audit POC submissions.
This has been noted as an agenda item to be reviewed during the regularly scheduled Directors Mandatory Monthly Meetings with the Regional Director.
This has been individually reviewed upon receipt of the email notification that was provided following the exit interview and is slated as an agenda item on the January 13, 2022 Regional Directors' Meeting.
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