INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 6-7, 2013 by staff from the Division of Drug and Alcohol 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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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of patient records, the facility failed to notify the patient, in writing, of a decision to involuntarily terminate the patient's treatment at the project in four of four records reviewed.
The findings include:
Nine patient records were reviewed on August 6-7, 2013. Four discharged patient records were reviewed for documentation of a termination letter. Patient records # 6, 7, 8, and 9 did not receive notice of their involuntary termination.
Client # 6 was involuntarily terminated from the program on August 5, 2013.
Client # 7 was involuntarily terminated from the program on June 11, 2013.
Client # 8 was involuntarily terminated from the program on June 2, 2013.
Client # 9 was involuntarily terminated from the program on June 10, 2013.
As of the date of inspection, there was no documentation of written notification to terminate patients # 6, 7, 8, or 9 from treatment.
The findings were reviewed with the clinical supervisor prior to the exit interview.
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Plan of Correction
Per Habit OPCO Policy 4.D.2, Patients may be discharged from the program for violating the program's policies. These discharges are considered either Emergency or Non-Emergency Discharges. When a patient is involuntarily discharged, provisions are made in writing to inform the patient of alternative services including other opioid programs, inpatient detox programs and other substance abuse programs. The patient will be given the information at the time of discharge or it will be mailed to them within 48 hours of discharge. This information will be documented in the patient record. The clinician will provide the notification and will be responsible for documenting it in the patient record. The Clinical Director will review this policy with clinicians in weekly supervision during the week of August 19, 2013, and will review the files of discharged patients to ensure compliance with policy (ongoing). |
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 psychosocial evaluations that provided the clinicians impressions of the patient in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in six of eight patient records reviewed.
The findings included:
Eight of the records were reviewed for the content of the psychosocial evaluation on August 6-7, 2013. The psychosocial evaluation is to be completed within thirty days of admission, as per agency policy. Patient records # 2, 3, 4, 5 and 9 failed to include a psychosocial evaluation that included a composite picture of the patient. Patient record #1 did not have documentation of a psychosocial evaluation at all.
Patient record #2 failed to include the patient ' s composite picture, the patient's assets and strengths, coping mechanisms, the negative factors that might inhibit treatment, and the patient's attitude toward treatment, and the counselor ' s clinical impressions. The documentation included a repeat of the patient's reported history and did not include an evaluation by the clinician for all required components.
The psychosocial evaluations in patient records # 3, 4, and 5 failed to include the patient ' s composite picture.
Patient # 1 was admitted into treatment on June 12, 2013 and the psychosocial evaluation was due by July 12, 2013. As of the date of inspection, there was no documentation of a psychosocial evaluation for patient #1.
This finding were reviewed with the clinical supervisor.
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Plan of Correction
Habit OPCO's assessment process includes two (2) services in our electronic health record: (1) "Diagnostic Evaluation" and (2) "Interpretive Summary". While we work to convert these to the EHR, there is also a paper Biopsychosocial Assessment. The Diagnostic Evaluation service contains historical self-reported data from the patient. This is the information that was viewed during the audit. The 'interpretive summary' provides the professional clinical input of the attending clinician. We believe that the inspector was not aware that both services occur at the same time, despite being documented in separate notes. Clinicians will receive training on August 19, 2013 related to the inclusion of a comment within the Diagnostic Evaluation that directs anyone who may be completing chart audits to view the interpretive summary.
During group supervision on 8/19, clinicians will be in-serviced on the completion of these services. Ongoing compliance with timeliness will be monitored by the Clinical Director via random chart audits (on going).
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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 the review of patient records, the facility failed to develop individual treatment and rehabilitation plans with the patient as stated in agency policy in four of six patient records.
The findings include:
Nine patient records were reviewed on August 6-7, 2013. Six patient records were required to have an individual treatment and rehabilitation plan developed with the patient within thirty days of admission, as per agency policy. The facility documented late treatment and rehabilitation plans in patient records # 2, 3, 4, and 6.
Patient #2 was admitted on May 20, 2013. An individual treatment and rehabilitation plan was due to be developed with the patient by June 20, 2013. The individual treatment and rehabilitation plan was developed on June 25, 2013.
Patient # 3 was admitted on April 16, 2013. An individual treatment and rehabilitation plan was due to be developed with the patient by May 16, 2013. The individual treatment and rehabilitation plan was developed on May 29, 2013.
Patient #4 was admitted on May 3, 2013. An individual treatment and rehabilitation plan was due to be developed with the patient by June 3, 2013. The individual treatment and rehabilitation plan was developed on June 25, 2013.
Patient #6 was admitted on February 22, 2013. An individual treatment and rehabilitation plan was due to be developed with the patient by March 22, 2013. The individual treatment and rehabilitation plan was developed on April 12, 2012.
These findings were reviewed with the clinical supervisor and were not disputed.
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Plan of Correction
Habit OPCO recognizes that individual treatment plans are required in the time frames established by regulation and Habit OPCO policy. During group supervision on 8/19, clinicians will be in-serviced on the timeliness of treatment plan entry. Ongoing compliance with timeliness will be monitored by the Clinical Director via random chart audits (on going). |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document a complete discharge summary that included the patient's reason for treatment and patient's status upon discharge in three of three patient records.
The findings include:
Nine patient records were reviewed on August 6-7, 2013. Three records were reviewed for discharge summaries. Patient records # 7, 8, and 9 did not include documentation of a discharge summary that included all required components.
Patient # 7 was admitted on April 9, 2013. The discharge summary dated June 18, 2013 failed to document the patient's reason for seeking treatment and the patient's status upon discharge.
Patient # 8 was admitted on May 17, 2013. The discharge summary dated June 3, 2013 failed to document the patient's reason for seeking treatment and the patient's status upon discharge.
Patient # 9 was admitted on May 17, 2013. The discharge summary dated June 17, 2013 failed to document the patient's reason for seeking treatment and the patient's status upon discharge.
This finding was discussed with the clinical supervisor.
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Plan of Correction
HOI-Watsontown staff will ensure that any individual notation entered related to a patients discharge are also included under the EHR's discharge summary tabulation category. In cases were a patient has been provided an intent to taper and or is a No Show for a significant amount of time to warrant a d/c notations are made in either a 'general contact' notation and/or an Administrative notation. During group supervision on 8/19, clinicians will be in-serviced on the preparation and distribution of these notifications. Ongoing compliance with timeliness will be monitored by the Clinical Director via random chart audits (on going). |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of patient records, the facility failed to document follow up information as per agency policy in one of three patient records.
The findings include:
Nine patient records were reviewed on August 6-7, 2013. Four discharged patient records were reviewed. Three of the four discharged patients had been discharged for the amount of time required for follow up contact. Per agency policy, follow up contact will be completed within 30 days of discharge for patients not referred to other programs. A follow up was not documented within 30 days of discharge in patient record # 8.
Patient #8 was discharged on June 2, 2013. A follow up contact was due to be completed by July 2, 2013. A follow up contact was not documented until July 9, 2013.
The findings were discussed with the clinical supervisor.
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Plan of Correction
Essential staff will be provided with additional Training on August 19, 2013 to ensure effective and timely completion of these follow up contacts post discharge and the timely notation of the same. During group supervision on 8/19, clinicians will be in-serviced on the timeliness of these entries. Ongoing compliance with timeliness will be monitored by the Clinical Director via random chart audits (on going).
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