INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection, conducted on March 23 - 24, 2015 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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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 the Staffing Requirements Facility Summary Report form, the facility failed to ensure all staff persons receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training.
The findings include:
The Staffing Requirements Facility Summary Report form was completed by the facility on February 20, 2015. The facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training. 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.
Employee # 4 a counselor was hired July 29, 2013. HIV/AIDS training and TB/STD training was to be completed within the first year of employment or by July 29, 2014. The facility failed to ensure employee # 4 completed the required training's at the time of inspection on March 24, 2015.
Employee # 5, the security guard was hired August 27, 2012. HIV/AIDS training and TB/STD training was to be completed within the first 2 years of employment or by August 27, 2014. The facility failed to ensure employee # 5 completed the required training's at the time of inspection on March 24, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Mandatory Communicable Disease Training was scheduled and completed by all identified staff members on Monday April 13, 2015. Certificates of completion have been documented in the staff members personnel records. Future recurrence of this deficiency will be prevented via assessment of staff training at the time of annual staff training plan development. The assessment will be completed by the Admin Assistant and will be reviewed by the Clinic Director during Q4 of each calendar year. |
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 facility's fire drill log, the facility failed to alternate exit routes and conduct fire drills on different staffing shifts.
The findings include:
On March 24, 2015, the facility's fire drill log was reviewed covering the period of March 2014 through February 2015. The facility failed to prepare alternate exit routes and conduct fire drills on different staffing shifts.
The facility documented 'front exit' during each monthly fire drill. In addition, the fire drills were only done on Saturday and Sunday during the 7 AM and 8 AM hour.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Drills will be expanded to include various times and the use of alternate egresses of which the facility has two (2). This process will be reviewed during the May 8, 2015 Monthly Staff meeting to ensure effective communication and implementation to the same.Quarterly reviews will be conducted by the Clinic Director to ensure compliance with this standard. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of administrative documentation, the governing body failed to make an annual report available to the public.
The findings include:
The facility's administrative documentation was reviewed on March 24, 2015.
The governing body failed to provide the annual report for the 2013/2014 fiscal year during the pre-submission process which was due February 20, 2014 or during the annual inspection which was conducted March 23 - 24, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that an annual report prepared for PA licensing standards will be offered for review and made available for public viewing. Notice that the plan is available for viewing will be filed as a legal notice in the Bar Association or Newspaper of the companies choice within 3 months of the publication of this report. Proof of publication will be provided annually upon reinspection. This will be reviewed by the Clinic Director annually. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of administrative documentation, the facility failed to file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the complaints of patient abuse (physical, verbal, sexual and emotional).
The findings include:
The facility's administrative documentation, including unusual incident reports was reviewed on March 24, 2015. The facility failed to file a complaint of patient abuse to the Department within 48 hours.
The findings were reviewed with facility staff during the methadone monitoring process.
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Plan of Correction
The Program Director, or their designee, will ensure that a Unusual Incident Report is filed with the Department in 48 hours if/when an event involving reports of: Abuse, Death or Serious injury, significant operational disruption, negative community impact or drug related hospitalization of a patient present themselves. This regulation will also be reviewed during the May 8, 2015 staff meeting to ensure any and all data is accurately captured for the Unusual Incident Report. Internal Incident reports will be reviewed and cross referenced against external reports on a quarterly basis, by the Regional Director, to ensure that this reporting is occurring as identified. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record which included documentation of case consultations in four of ten and a discharge summary in one of four client records.
The findings include:
Ten client records were reviewed on March 24, 2015. The facility failed to document a complete client record which included case consultations in four of ten records, and a discharge summary in one of four client records required; client record # 6, 8, 9, and 10.
Client # 6 was admitted to the program on January 26, 2013. The facility failed to document a complete client record which included a case consultation in client record # 6.
Client # 8 was admitted to the program on November 13, 2014. The facility failed to document a complete client record which included a case consultation in client record # 8.
Client # 9 was admitted to the program on November 25, 2014. The facility failed to document a complete client record which included a case consultation in client record # 9.
Client # 10 was admitted to the program on July 18, 2014. The facility failed to document a complete client record which included a case consultation and a discharge summary in client record # 10.
The findings were reviewed with facility staff during the inspection process
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Plan of Correction
The Program Director, or their designee, will ensure that an updated training is completed with all staff regarding the proper and timely completion of documentation required in the Patient chart. This training will occur during the Monthly Staff meeting on May 8, 2015. The auditor's report and findings will be included as examples for this effort.Ongoing comkpliance with the timely documentation will be reviewed via quarterly chart audits of open and closed records by the Regional Director or designee. |