INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 11-12, 2016 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:
|
Plan of Correction
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of personnel records, the facility failed to provide documentation of individual training plans in two of six personnel records reviewed.
The findings include:
Six personnel records requiring documentation of individual training plans were reviewed on February 11, 2016. The facility training year runs from January 1 to December 31. The facility failed to provide documentation of individual training plans for employees #1 and #6.
Employee # 1 was hired on November 29, 2011 and the individual training plan was not documented for the 2016 training year.
Employee # 6 was hired on December 28, 2015 and the individual training plan was not documented for the 2016 training year.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The program director will ensure that any and all trainings documentations required for on-site inspections, including the Individual Annual Training Plan, are available and/or if they have been modified due to acquisition protocol, that there is some other form of notification/draft from the appropriate level parties; that is viable and available for review/consideration to ensure compliance to 704.11(b)(1).
Additionally the program director will review with onboarding and management team during our monthly staff meeting on Thursday, March 10, 2016, the importance to ensure new hire paperwork, to include Individual training plans, are prepared at the point a new staff member commences their employ; regardless of the point within the training year. As for staff member #6, the said plan was provided on 3/3/2016 upon their return to work, for completion and review with their supervisor. It will be filed accordingly within their personnel record and ready for review in compliance to policy 704.11(b)(1).
|
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director.
The findings include:
The personnel record of the project director requiring the documentation of the completion of 12 clock hours of annual training was not provided at the time of inspection on February 11, 2016. Employee # 1 was hired on November 29, 2011 as project director. The training year for January 1, 2015 to December 31, 2015 was reviewed. The facility failed to provide documentation of the completion of 12 clock hours of annual training for employee #1.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The program director will ensure that any and all trainings documentations required for on-site inspections are available and/or if they have been modified due to acquisition protocol, that there is some other form of notification/draft from appropriate level parties that is viable and available for review/consideration to ensure compliance to 704.11(d)(2).
The Program director will inquire as to the re-acquisition of completed trainings misplaced via acquisisiton(s) and ensure that they may be replaced into the Project director's personnel file in additon to any further trainings comleted during 2016. |
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.
|
Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of the fire extinguisher within seven days of staff employment, in one of six personnel records.
The findings include:
Six personnel records were reviewed on February 11, 2016. The facility failed to document the completion of fire extinguisher training within seven days of staff employment in personnel record #6.
Employee # 6 was hired on December 28, 2015. The training was due within seven days, by January 4, 2016.
These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
The program director will review with on-boarding and management team, during regular monthly staff meetings, commencing with Thursday, March 10, 2016, the importance to ensure new hire paperwork, to include Fire Extinguisher training and instruction, are prepared at the point a new staff member commences their employ; regardless of the point within the training year.
As for staff member #6, Fire Extinguisher training was provided to them on March 3, 2016 upon their return to work. Their successful completion to this training and subsequent graded quiz has since been reviewed by thier supervisor, signed and filed in their personnel file, in compliance to policy 705.28(c)(4).
The onsite Admin. Asst. will ensure that all such training and appropriate documentation to the same are completed and filed accordingly in personnel files for all new hires. The Center Director, will enusure compliance of this staff members execution of this duty on a bi-annual or as needed basis.
As noted, herein, at the time of this draft, staff member #6's training is completed, recorded and has been added to their personnel file. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies, in one of six personnel records reviewed.
The findings include:
Six records requiring documentation that personnel on all shifts were trained to perform assigned tasks during emergencies, were reviewed on February 11, 2016.
Employee # 6 was hired on December 28, 2015. There was no documentation of training for assigned tasks during emergencies in the personnel record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will ensure to express to all hiring managers and on-boarding personnel during the next Monthly staff meeting on Thursday, March 10, 2016, as well as to all staff, the need to ensure that all personnel are trained as to their duties in the event of an emergency; regardless of whether or not they may be in orientation or not.
The meeting notations/agenda from the March 10, 2016 staff meeting will serve as record to the corrective measure of this deficiency along with enforcing future compliance to policy 705.28(d)(3).
On March 3, 2016, upon Employee #6's return to work, she completed a training as to fire extinguisher locations and use along with a review of Emergency procedures and protocols specific to the Center and each staff members roles, to ensure Pt. and staff safety in the event of an emergency. Completion of this training et al have been filed in Employee #6's personnel file.
The Admin. Asst. will, as is thier job duty, ensure that all such trainings are done timely upon a new hires orientation to ensure this deficiency is not repeated. Reviews to support compliance to regulation P277 will be conducted bi-annual, or as needed, by the Center Director.
|
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
|
Observations
Based on a review of personnel records, the facility failed to document a written job description in one of six personnel records reviewed, as required by regulation.
The findings include:
Six personnel records were reviewed on February 11, 2016. The facility failed to obtain the required documentation of a job description in personnel record #1.
Employee # 1 was hired on November 29, 2011 as Regional Director. There was no personnel record or documentation of a job description provided for employee #1 at the time of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The program director will ensure that any and all new hire paperwork and documents, to include signed job descriptions are available for on-site inspections. If, through acquisition or some other staffing pattern adjustment or acquisition, that there is some other form of notification/draft from appropriate level parties that is viable and available for review/consideration to ensure compliance to 709.26(f).
This matter will also be presented to all HR, on-boarding and management personnel during the March 10, 2016 monthly staff meeting.
|
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:
|
Observations
Based on the review of client records, the facility failed to a document, timely or complete individual treatment and rehabilitation plans in six of ten records.
The findings include:
Ten client records were reviewed on February 11-12, 2016.
Client #2 was admitted on July 29, 2015 and the treatment and rehabilitation plan was due on August 29, 2016 but was not completed until September 17, 2015. Type and frequency of services was missing from the treatment and rehabilitation plans in the patient record.
Client #3 was admitted on December 5, 2014 and the treatment and rehabilitation plan stated "up to 4 I and 4 G per month" for the type and frequency of services.
Client #6 was admitted on August 22, 2014 and the treatment and rehabilitation plan stated "up to 4 I and 4 G per month" for the type and frequency of services.
Client #7 was admitted on July 22, 2015 and the treatment and rehabilitation plan was due on August 22, 2015 but was not completed until September 8, 2015. Type and frequency of services stated "up to 4 I and 4 G per month."
Client #8 was admitted on November 16, 2015 and the treatment and rehabilitation plan was due on December 16, 2015 but was never completed.
Client #10 was admitted January 20, 2016 and is still an active client. The treatment and rehabilitation plan stated "up to 4 I and 4 G per month" for the type and frequency of services.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical personnel will be provided with a training related to timely Tx plan completion and to accurate type and frequency measures for clinical compliance.
This training will (was) be offered on March 10, 2016 along with further supervisory oversight and review throughout the calendar year to ensure compliance and on-going training to policy 709.92.
Various options will be reviewed, during regular supervision, to assist clinical personnel with Pt. engagement to this process.
Additionally use of the various options available with the Electronic Health Record on site will be explored to ensure continued compliance to the completion of these documents in a more timely fashion in concert with the fully operational EHR on site.
The Center Director will review the compliance of staff to this metric to ensure this deficiency does not reoccur. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
|
Observations
Based on a review of client records, the facility failed to document a physician signature on the individual treatment and rehabilitation plan for medical assistance clients.
The findings included:
Ten client records were reviewed on February 11-12, 2016.
Client #1 was admitted to outpatient treatment on January 25, 2016. The individual treatment and rehabilitation plan was developed on February 4, 2016, and did not include a physician signature.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A review with medical and nursing personnel will (was) be conducted on Tuesday, March 8, 2016 as to the need to ensure that the signing of individual training plans for all patients served are reviewed and authorized in accordance to 709.94(g).
A review of the process by which staff have effectively engaged in this process will be examined to correct this cited error to ensure compliance in its entirety.
The Center director, or their nursing/medical designee, will provide on-going reviews, in concert with the Regional Medical Director, to ensure this practice is compliant and does not reoccur. |