INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on March 24-25, 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, the facility failed to ensure the employee #3 received at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 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.
This is a repeat citation from the November 18, 2021 licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director, Assistant Director and Clinical supervisor will ensure all Employees are up to date with TB/STD, Communicable disease and other health related trainings by 2022.
The CTC Director will review with each manager and all new hires the need to ensure TB/STD and communicable disease trainings are scheduled and completed within accordance to regulatory policy timelines.
Clinical Supervisor will continue tracking and updating compliance monthly on training excel sheet.
Employee #3 is scheduled to complete TB/STD and HIV/AIDS on 5/26/22.
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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 four out of ten patient records, as the form did not list what specific information could be released.
Patient #1 was admitted on February 22, 2022 and was still active at the time of the inspection. A consent form was dated February 22, 2022 to a community organization.
Patient #2 was admitted on February 17, 2022 and was still active at the time of the inspection. A consent form was dated February 17, 2022 to a community organization.
Patient #3 was admitted on February 2, 2022 and was still active at the time of the inspection. A consent form was dated February 8, 2022 to a community organization.
Patient #9 was admitted on March 13, 2018 and was still active at the time of the inspection. Two consent forms dated February 7, 2022 were to a family member and a physician.
This is a repeat citation from the November 18, 2021 licensing inspection.
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 6/1/22. All staff will have a release of records training by 6/1/22 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, Assistant Director, and Clinical supervisor 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 February 27-March 5, 2022, the patient census was 232. The facility was required to provide at least 23.2 physician hours. There were 12.5 hours documented.
During the week of March 6-12, 2022, the patient census was 230. The facility was required to provide at least 23 physician hours. There were 10.75 hours documented.
This is a repeat citation from the November 18, 2021, November 6, 2020, November 26, 2019, November 28, 2018, December 13, 2017, and April 26, 2017, annual licensing inspections.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director and assistant 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 4/1/22 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 and Charge nurse will monitor the calendar weekly to ensure there is adequate coverage between MDs and PA/CRNP.
As of 5/23/22 a Physician assistant was hired to provide more coverage between MD's and PA/CRNP. If warranted CTC Director will add additional practitioner(s) to the team as needed.
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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 the review of patient records, the facility failed to document a completed annual physical examination in one out of one applicable record.
Patient #9 was admitted on March 13, 2018 and was still active at the time of the inspection. The annual physical was due on March 13, 2022; however, there was no documentation of it being completed.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director and Charge nurse will ensure all patient physical examinations are completed in timely manner per company policy and 715.23b.
CTC Director will review with Charge nurse by 6/1/22 to ensure SMART EMR reports are run monthly and patient is scheduled for physical exam by annual admission date.
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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 in three out of the three applicable records.
Patient #8 was admitted on March 17, 2017 and was still active at the time of the inspection. The annual evaluation was due on March 17, 2022; however, there was no documentation of it being completed.
Patient #9 was admitted on March 13, 2018 and was still active at the time of the inspection. The annual evaluation was due on March 13, 2022; however, there was no documentation of it being completed.
Patient #10 was admitted on February 22, 2016 and was still active at the time of the inspection. The annual evaluation was due on February 22, 2022; however, there was no documentation of it being completed.
This is a repeat citation from the November 18, 2021 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
CTC Director will complete quarterly chart to charge reviews to ensure accurate record keeping and oversee overall chart compliance.
CTC Director will Submit an I.T. ticket so that the EMR will auto-populate the annual clinical evaluation on the patient's anniversary date.
The Clinical Supervisor will continue to run monthly SMART EMR reports to ensure clients annual evaluation is completed within patient's anniversary date.
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709.92(a) 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:
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Observations
Based on a review of patient records, the facility failed to develop an individual treatment plan with the client in two out of four applicable records.
Patient #1 was admitted on February 22, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was due to be completed by March 22, 2022. There was no treatment plan documented in the patient's record.
Patient #2 was admitted on February 17, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was due to be completed by March 17, 2022. There was no treatment plan documented in the patient's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will review with Clinical Supervisor to ensure treatment plans are done timely according to company policy and 709.92a. by 6/1/22.
CTC Director and Clinical Supervisor will review treatment plan completion within policy timeframe at monthly counseling staff meeting on June 13, 2022.
Clinical Supervisor will continue to run treatment plan reports in (SMART) EMR system monthly to ensure all treatment plans are completed within policy timeframe.
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709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of patient records, the facility failed to document frequency of treatment services in two out of two applicable records.
Patient #3 was admitted on February 2, 2022 and was still active at the time of the inspection. A comprehensive treatment plan dated February 24, 2022 stated "up to 2.5 hours" of individual therapy per month.
Patient #4 was admitted on February 22, 2022 and was still active at the time of the inspection. A comprehensive treatment plan dated March 4, 2022 stated "up to 2.5 hours" of therapy monthly.
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 to receive training on the necessity of counseling time documented in treatment plans.
The CTC Director and Clinical Supervisor will review with counseling team on 6/13/22.
Clinical Supervisor will ensure Counseling team is trained by 6/13/22 to ensure counseling documentation in treatment plan is adhering to requirements of 709.92(a)(2).
Clinical Director will ensure Clinical Supervisor reviews all Treatment plans monthly upon completion. Clinical supervisor runs SMART EMR reports monthly to ensure all treatment plans are completed within policy timeframe.
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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 two out of the two applicable records.
Patient #3 was admitted on February 2, 2022 and was still active at the time of the inspection. The treatment plan was dated February 24, 2022.
Patient #4 was admitted on February 22, 2022 and was still active at the time of the inspection. The treatment plan was dated March 4, 2022.
This is a repeat citation from the November 18, 2021 licensing 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 the counseling team to be retrained on the necessity of including support services to all patient treatment plans.
Clinical Supervisor will ensure training is completed on June 13, 2022 during monthly meeting.
CTC Director in concert with RD will ensure treatment plans in SMART EMR are updated to add support services to application.
CTC Director will ensure Clinical Supervisor is reviewing SMART EMR reports monthly and reviewing all treatment plans to ensure support services are documented.
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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 two out of six applicable records reviewed.
Patient #5 was admitted on November 30, 2021 and was still active at the time of the inspection. A treatment plan dated February 1, 2022 indicated 2.5 hours of therapy per month. In February 2022, the patient received a total of 2 hours, 12 minutes of individual therapy.
Patient #6 was admitted on November 9, 2021 and was still active at the time of the inspection. A treatment plan dated January 11, 2022 indicated 30 minutes of individual therapy and 2 hour of group therapy per month. In February 2022, the patient received one hour of group therapy.
This is a repeat citation from the November 18, 2021 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will review with Clinical Supervisor to ensure counseling services are completed according to treatment plan per 709.92(c).
CTC Director and Clinical Supervisor will continue to utilize SMART EMR reports that are run weekly to ensure counseling is completed and reviewing non-compliant clients on report.
Clinical Supervisor will continue counselor supervision sessions weekly to review client non-compliance and come up with a plan for client to comply with treatment plan.
Proper documentation of client no-shows, cancellations along with treatment plan updates in order for patient to gain compliance will be reviewed during counseling staff monthly meeting on 6/13/22.
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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 18, 2021, November 6, 2020, November 26, 2019, November 28, 2018, 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.
This is a repeat citation from the November 18, 2021 licensing inspection.
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Plan of Correction
The Regional Director will review weekly with CTC Director and Assistant Director to ensure facility complies with plan of correction as to physician coverage.
The Regional Director will ensure CTC Director and Assistant Director are reviewing physician coverage weekly to comply with 715.6 (e). This will be monitored by review of physician timesheets and CTC Census.
As of 5/23/22 a Physician assistant was hired to provide more coverage between MD's and PA/CRNP. If necessary CTC Director will add additional practitioner(s) to the team as needed.
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