INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 20-21, 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to document fire extinguisher training upon staff employment.
The findings include:
Four personnel records were reviewed on February 20, 2013. One record was reviewed to verify that staff had been instructed in the use of a fire extinguisher upon employment.. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record # 4.
Employee # 4 was hired on 9/10/2012. Fire extinguisher training was due upon hire. The facility failed to document fire extinguisher training in this record as of the time of the inspection.
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Plan of Correction
Fire extinguisher training shall be made available to all staff members upon hire. The timeframe for completion of this is documented on the orientation checklist for new hires. The administrative assistant will verify that the orientation checklist is completed and filed as required by policy. An independent semi-annual review of personnel files by the Facility Director will ensure that this is being completed as required. The administrative assistant received inservice training on the need to verify that this documentation is placed in the personnel file, and in the event that the proper documentation was not forwarded for filing, to notify the Director, in writing. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill logs, the facility failed to conduct unannounced fire drills at least once per month in three of ten months reviewed.
The findings include:
The fire drill logs were reviewed on February 20, 2013. The facility received their license on May 15, 2012. There was no documentation of unannounced fire drills for the months of May 2012, June 2012, and July 2012.
A discussion with the Clinical Supervisor regarding this issue took place on February 20, 2013 and the finding was not disputed.
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Plan of Correction
Habit OPCO will perform fire drills on a monthly basis (at different times of the day) in accordance with the cited regulation. These will be conducted by a security associate. The Facility Director will perform quarterly checks of the fire drill log to verify that the systems have been checked. Ongoing. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills were conducted during different times of the day.
The findings include:
The fire drill record was reviewed on February 20, 2013. Seven months of fire drills were reviewed. The facility's hours of operation are from 6:00 a.m. until 2:00 p.m. The facility failed to document fire drills between the hours of 6:00 a.m.- 9:00 a.m. which is the facility's busiest time for patients to be at the clinic. There were no drills were documented between the hours of 10:45 a.m. and 2:00 p.m.
This finding was discussed with the Clinical Supervisor and was not disputed.
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Plan of Correction
Staff members will be inserviced on regulation 705.28 at a staff meeting to be conducted on Friday, March 22, 2013. The inservice will include information regarding the importance for fire drills to occur at varying times during the 8 hours of daily clinic operations. To prevent this deficiency from recurring, the facility director will review the recorded fire drills quarterly to validate that variations in times are occurring as required. Ongoing. |
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 the review of patient records, the facility failed to ensure the patient was notified that a consent to release could be revoked verbally in eight of eight records reviewed. The facility also released information to an outside agency prior to obtaining written consent from the patient in two of eight records reviewed.
The findings included:
Eight patient records were reviewed February 20-21, 2013. Eight records were reviewed regarding release of information documentation. The facility failed to ensure the patient was informed they could revoke a consent to release verbally in patient records # 1, 2, 3, 4, 5, 6, 7, and 8. Additionally, patient records # 3 and 5 failed to include a consent to release prior to obtaining information about the patient from an outside agency.
A review of patient record # 3 revealed information was released to a funding source. The record included a Pennsylvania Client Placement Criteria form that was faxed to the insurance company without a consent to release from the client.
A review of patient record # 5 revealed information received from an outside agency. The fax cover sheet from the outside agency indicated that they were forwarding the information that was requested from the facility. The facility failed to obtain a consent to release information signed by patient # 5 prior to contacting the outside agency.
These finding were reviewed with the clinical supervisor and were not disputed.
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Plan of Correction
The hardcopy consent form (the non-Electronic Health Record Format) will be modified to include language that ensures patients are provided with information specific to their right to revoke consent verbally. Additionally, the consent form will also be modified to include a signature line for a witness.
Staff members will be trained on the use of the new format AND on the purpose and scope of consent in accordance with 42 CFR Part 2 and 4 PA Code 255.5 (to include not releasing information without a signed consent form) at a staff meeting on April 3, 2013.
The clinical director will conduct quarterly reviews to ensure that the consent forms are completed and properly filed. Ongoing. |
709.28(c)(5) 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:
(5) Dated signature of witness.
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Observations
Based on the review of patient records, the facility failed to obtain an informed and voluntary consent from the client that included a dated signature of a witness in five of eight records reviewed.
The findings include:
Eight patient records were reviewed on February 20-21, 2013. All patient records included informed and voluntary consent to release documentation. The facility failed to include a dated signature of a witness on the informed voluntary consent to releases included in patient records # 1, 2, 4, 6 and 8.
This finding was reviewed with the clinical supervisor and was not disputed.
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Plan of Correction
The hardcopy consent form (the non-Electronic Health Record Format) will be modified to include language that ensures patients are provided with information specific to their right to revoke consent verbally. Additionally, the consent form will also be modified to include a signature line for a witness. Staff members will be trained on the use of the new format at a staff meeting on March 22, 2013. The clinical director will conduct quarterly reviews to ensure that the consent forms are completed and properly filed. Ongoing. |
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 the facility's policy and procedures, the facility failed to ensure that verbal medication orders were put in writing and signed with 24 hours thereafter by the prescribing physician, as required by regulation and facility policy and procedure, in six of eight patient records.
The findings include:
Eight patient records were reviewed on February 20-21, 2013. All verbal medication orders are required to be signed within 24 hours by the prescribing physician. Patient records # 1, 2, 4, 5, 6 and 8 contained verbal medication order that was not signed by the prescribing physician within 24 hours. Patient record # 2 also contained a verbal order that was signed off by someone other than the prescribing physician.
Patient #1 was admitted on February 2, 2013 and discharged February 10, 2013. Verbal orders contained in the patient record dated February 6, 2013 were not signed off within 24 hours. The prescribing physician signed off on the verbal order on February 9, 2013. This record also contained a verbal order dated February 10, 2013. The prescribing physician did not sign off on the verbal order until February 16, 2013.
Patient #2 was admitted on November 15, 2012. A verbal order dated November 19, 2012 was not signed by the prescribing physician until December 7, 2012. A verbal order dated January 19, 2013 was not signed by the prescribing physician; another narcotic treatment physician signed off on this verbal order on January 19, 2013. A verbal order dated January 24, 2013 was not signed by the prescribing physician until January 26, 2013. A verbal order dated February 2, 2013 was not signed by the prescribing physician until February 9, 2013.
Patient # 4 was admitted on November 15, 2012. A verbal order dated November 19, 2012 was not signed by the prescribing physician until December 7, 2012.
Patient # 5 was admitted October 24, 2012 and was discharged on December 25, 2012. This record contained verbal orders on October, 27, 2012, October 30, 2012, November 2, 2012 and November 5, 2012. These verbal orders were not signed off until November 7, 2012. The record also contained verbal orders on November 8, 2012 and November 11, 2012. These verbal orders were not signed off until November 14, 2012. The record also contained a verbal order on December 10, 2012 that ws not signed off until December 17, 2012.
Patient # 6 was admitted on October 10, 2012 and discharged on November 2, 2012. A verbal order dated October 14, 2012 was not signed by the prescribing physician until October 17, 2012. The record also contained verbal orders dated October 19, 2012 and October 22, 2012. These verbal orders were not signed off until October 24, 2012. The record also contained verbal orders dated October 25, 2012 and October 28, 2012. These orders were not signed off until November 7, 2012.
Patient # 8 was admitted on November 2, 2012. A verbal order dated November 11, 2012 was not signed off by the prescribing physician until November 14, 2012. The record also contained verbal orders dated November 15, 2012 and November 19, 2012. These verbal orders were not signed off until December 7, 2012.
The above information was reviewed with the clinical supervisor and were not disputed. This is a repeat citation from the September 5-6, 2012 monitoring inspection.
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Plan of Correction
The Facility Director will circulate information regarding the requirement to all physicians working at the Watsontown facility. Physicians in Watsontown have been provided with remote access to the EHR. The Nurse Manager will conduct quarterly audits on the patient records to verify that patient verbal orders are signed within 24 hours. |
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 administrative documentation, the facility failed to provide at least one hour of physician time a week, onsite for, every ten patients for six of the twenty weeks reviewed.
The findings include:
Physician time sheets for the months of October, November, December, January and February were reviewed on February 20, 2013. Twenty weeks were reviewed along with the average census for those weeks. Six weeks provided insufficient onsite physician hours during November, December, and January.
During the week of November 18-24, 2012, the patient census was 33. The facility was required to provide at least 3 physician hours. There were no physician hours documented.
During the week of December 9-15, 2012, the patient census was 33. The facility was required to provide at least 3 physician hours. There were no physician hours documented.
During the week of December 23-29, 2012, the patient census was 32. The facility was required to provide at least 3 physician hours. There were no physician hours documented.
During the week of January 6-12, 2013, the patient census was 32. The facility was required to provide at least 3 physician hours. There were no physician hours documented.
This finding was confirmed by the Clinical Supervisor on February 20, 2013. This is a repeat citation from the September 5-6, 2012 monitoring inspection.
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Plan of Correction
Habit OPCO acknowledges the need for 1 hour of onsite physician coverage (weekly) for every 10 patients on the census. Since the abrubt departure of our previous medical director, Habit OPCO has hired two (2) physicians who currently provide eighteen (18) hours per week. Having two physicians eliminates the risk of lack of coverage in the future. The nurse manager will review physician staffing schedules to ensure that staffing always exceeds the ratio identified in regulations. Ongoing. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on the review of clinical documentation, the facility failed to document the basis for determining current and one year dependency in one of one record reviewed.
The findings include:
Eight patient records were reviewed on February 20-21, 2013. One patient record was reviewed for physician documentation of the basis for determining current and one year history of dependency. The facility failed to document dependency for one year prior to the admission in patient record # 5
Patient # 5 was admitted on October 24, 2012. Review of the patient record revealed the patient had been in a detox program in the past year. The patient attended a six day detoxification program from October 10-16, 2012. The patient failed to meet the one year dependency requirement and the facility did not submit an exception request to the Department for this admission.
This is a repeat citation from the September 5-6, 2012 monitoring inspection.
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Plan of Correction
The Chief Medical Officer or designee will provide inservice training (verbally or in writing) to the Watsontown Medical Director to ensure that the physician understands how to document the history of abuse in conformance with these regulations. The nurse manager will review the notes (by random sample quarterly) to evaluate compliance with this requirement. 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 six records reviewed.
The findings included:
On February 20-21, 2013, eight patient records were reviewed. Six of the records were reviewed for the content of the psychosocial evaluation. Patient records # 2, 3, 4. 5 and 8 failed to include a psychosocial evaluation that included a composite picture of the patient's problems and needs to be addressed in treatment, the patient's assets and strengths, coping mechanisms, support systems, the negative factors that might inhibit treatment, and the patient's attitude toward treatment. The documentation included a repeat of the patient's reported history and did not include an evaluation by the clinician for all required components.
This finding was reviewed with the clinical supervisor and was not disputed.
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Plan of Correction
At the time of the inspection, there was one (1) clinician. She will be trained on the documentation of clinical impressions in an individual supervisory session on March 20, 2013. Followup on this issue, with this clinician, will occur on a weekly basis during individual clinical supervision. The Clinical Director will also document compliance with these via ongoing quarterly chart reviews. |
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 six of eight records.
The findings include:
Eight patient records were reviewed on February 20-21, 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 failed to document an individual treatment and rehabilitation plan in patient record # 3. The facility documented late treatment and rehabilitation plans in patient records # 2, 3, 4, 5, and 8.
Patient #2 was admitted on November 15, 2012. An individual treatment and rehabilitation plan was due to be developed with the patient by December 15, 2012. The individual treatment and rehabilitation plan was developed on January 4, 2013.
Patient # 3 was admitted on January 19, 2013. An individual treatment and rehabilitation plan was due to be developed with the patient by February 19, 2013. As of the date of the inspection, there was no individual treatment and rehabilitation plan in the patient record.
Patient #4 was admitted on November 15, 2012. An individual treatment and rehabilitation plan was due to be developed with the patient by December 15, 2012. The individual treatment and rehabilitation plan was developed on January 11, 2013.
Patient #5 was admitted on October 24, 2012. An individual treatment and rehabilitation plan was due to be developed with the patient by November 24, 2012. The individual treatment and rehabilitation plan was developed on December 19, 2012.
Patient #8 was admitted on November 2, 2012. An individual treatment and rehabilitation plan was due to be developed with the patient by December 2, 2012. The individual treatment and rehabilitation plan was developed on January 7, 2013.
These findings were reviewed with the clinical supervisor and were not disputed.
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Plan of Correction
At the time of the inspection, there was one (1) clinician. She will be trained on policy related to individual treatment and rehabilitation plans in an individual supervisory session on March 20, 2013. Followup on this issue, with this clinician, will occur on a weekly basis during individual clinical supervision. The Clinical Director will also document compliance with these via ongoing quarterly chart reviews |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of patient records, the facility failed to document case consultations in two of three records reviewed.
The findings include:
Eight patient records were reviewed on February 20-21, 2013. Three of the eight patient records records were required to document case consultations. Case consultations were not completed in patient records # 2 and 4.
Patient # 2 was admitted to outpatient treatment on November 15, 2012. A case consultations was due to be completed by February 15, 2012. The case consultation was not documented.
Patient # 4 was admitted to outpatient treatment on November 15, 2012. A case consultations was due to be completed by February 15, 2012. The case consultation was not documented.
These findings were discussed with the clinical supervisor and were not disputed.
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Plan of Correction
At the time of the inspection, there was one (1) clinician. She will be trained on the documentation of case consultation notes in an individual supervisory session on March 20, 2013. Followup on this issue, with this clinician, will occur on a weekly basis during individual clinical supervision. The Clinical Director will also document compliance with these via ongoing quarterly chart reviews |
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, services offered, response to treatment and patient's status upon discharge in three of three patient records.
The findings include:
Eight patient records were reviewed on February 20-12, 2013. Three records were reviewed for discharge summaries. Patient records 1, 5, and 6 did not document a discharge summary that included all required components.
Patient # 1 was admitted on 2/2/2013 and discharged on 2/10/2013. The discharge summary failed to document the patient's reason for seeking treatment, response to treatment and the patient's status upon discharge.
Patient # 5 was admitted on 10/24/2012 and discharged on 12/25/2012. The discharge summary failed to document the patient's reasons for treatment, response to treatment and the patient's status upon discharge.
Patient # 6 was admitted on 10/10/2012 and discharged on 11/2/2012. The discharge summary failed to document the patient's reasons for treatment, response to treatment, and the patient's status upon discharge.
This finding was confirmed with the clinical supervisor.
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Plan of Correction
At the time of the inspection, there was one (1) clinician. She will be trained on the documentation of discharge summaries in an individual supervisory session on March 20, 2013. Followup on this issue, with this clinician, will occur on a weekly basis during individual clinical supervision. The Clinical Director will also document compliance with these via ongoing quarterly chart reviews |
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 two patient records.
The findings include:
Eight patient records were reviewed on February 20-21, 2013. Three discharged patient records were reviewed. Two of the three 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. Follow up was not documented within 30 days of discharge in patient record #5.
Patient #5 was admitted to treatment on October 24, 2012 and discharged on December 25, 2012. A follow up contact was due to be completed by January 25, 2013. There was no follow up contact documented in patient record #5.
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Plan of Correction
At the time of the inspection, there was one (1) clinician. She will be trained on the documentation of followup information in an individual supervisory session on March 20, 2013. Followup on this issue, with this clinician, will occur on a weekly basis during individual clinical supervision. The Clinical Director will also document compliance with these via ongoing quarterly chart reviews |