INITIAL COMMENTS
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This report is a result of an on-site inspection to this newly licensed facility following the admittance of its first client. The inspection was conducted on June 7, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of this on-site inspection, Habit Opco, Inc. was to not 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the observation during the physical plant inspection, the facility failed to ensure that group counseling sessions could not be seen.
The findings include:
During the physical plant tour on June 7, 2012, it was observed that a group room to a lacked window coverings to ensure privacy in order that group counseling sessions could not be seen.
The findings were reviewed with the lead counselor and were not disputed.
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Plan of Correction
The group room in question, (Group Room "B") has a small window on the door. On June 26, 2012, the Facility Director installed a window covering on the window thereby preventing counseling from being seen.
Ongoing compliance with this standard will be monitored during weekly safety and sanitation inspections by the facility security staff. Any non-compliance will be documented in the safety inspections and will be promptly addressed by the security associate.
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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 a review of patient records, the facility failed to have a narcotic treatment physician make a face-to face determination and document in the patient's record the basis for determining an individual's physiological dependence upon a narcotic drug in 13 of 13 records.
Findings:
Thirteen patient records were reviewed on June 7, 2012. All of the records were required to provide documentation of a face-to-face assessment by the the physician to determine the patient's physiological dependence upon a narcotic drug. In all thirteen records, there was no documentation that presented a determination by the physician that the patient was currently dependent on a narcotic drug and possessed at least one year's current dependency at the time of admission.
The findings were reviewed with the lead counselor and were not disputed.
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Plan of Correction
While conducting face-to-face evaluations with patients, the Physician had not document the Habit OPCO form titled "medical admission note".
Since the site visit, the Physician's work has been reviewed by the Chief Medical Officer. The Physician will be provided copies of the appropriate form and will be trained by the Chief Medical Officer on the completion of this form. The training will be completed by 7/17 (this time frame has been determined because the Physician in question is teaching in France and will not return to the country until July 14).
Ongoing compliance will be monitored by the Physician, the charge nurse, and the Facility Director through bi-weekly random chart audits.
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715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility exceeded 30 mgs for a patient's initial dose in one of thirteen records reviewed.
The findings include:
A review of thirteen patient records on June 7, 2012 revealed that the facility had exceeded 30 mgs. for the initial dose without documentation by the physician that addressed the reason for the dose. Patient # 6 was given a dose of 40 mgs. on June 5, 2012.
According to regulations 42 CFR, Part 8, the initial dose may not exceed 30 mgs. without documentation by the physician that indicated the reason for the additional medication as well as documents the patient response to the initial dose.
The findings were discussed with the lead counselor who was able to explain patient # 6 had been a readmit but the physician had failed to record the rationale and reasons for determining this dose.
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Plan of Correction
The Medical Director and/or any other Narcotic Treatment Physician at Habit OPCO will document the rationale for an initial dose whenever the dose exceeds 30 mgs (this includes new patients and readmissions). This information will be documented in the face-to-face assessment and/or in medical doctor assessment notes.
Ongoing compliance will be monitored by the Physician, the charge nurse, and the Facility Director through bi-weekly random chart audits.
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715.21 LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
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Observations
Based on a review of patient handbook the facility failed to restrict their policy and procedure on involuntary terminations to those areas specified in the regulations.
The findings include:
A review of the patient handbook on June 7, 2012 revealed that patients were informed they could be terminated for reasons other that those specified by regulations. According to the handbook documentation, patients could be terminated for reasons such as loitering, illicit drug use, funding/insurance issues and nonpayment for treatment services.
The findings were discussed with the lead counselor and were not disputed.
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Plan of Correction
715.21 indicates that involuntary termination from the program may be initiated if the program deems that the termination would be in the best interests of the health or safety of the patient and others, or if the program finds any of the following conditions exist:
(i) the patient has committed acts of physical violence in or around the narcotic treatment program premesis.
(ii) the patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premesis.
(iii) the patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) the patient has failed to follow treatment plan objectives.
Additionally, 715.21 indicates that "a patient terminated involuntarily, except a patient who commits or threatens to commit acts of physical violence, shall be afforded the opportunity to receive detoxification of at least seven days. The detoxification may take place at the facility..."
Habit OPCO will ensure that discharge recommendations are compliant with 715.21 by adding language to treatment plans that clearly identifies the need to maintain compliance with Habit OPCO established rules. This will ensure that discharges are always in compliance with treatment plan compliance as required by 715.21
Ongoing compliance will be monitored by the Facility Director and/or lead clinician through bi-weekly random chart audits.
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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 discharge summary within one week of discharge in two of four patient records.
The findings include:
Thirteen patient records were reviewed on June 7, 2012. Per agency policy, discharge summaries are due within one week of discharge. Discharge summaries were required in three patient records. The facility did not document a discharge summary within one week of discharge in patient records # 2 and 3. .
Client # 2 was admitted on April 3, 2012 and was discharged on April 19, 2012. At the time of the on-site review there was no discharge summary available for review.
Client # 3 was admitted on March 22, 2012 and was discharged on April 16, 2012. At the time of the on-site review there was no discharge summary available for review.
The findings were discussed with the lead counselor and were not disputed.
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Plan of Correction
Habit OPCO's lead clinician incorrectly identified that discharge summaries are required within seven (7) days of discharge. The Habit OPCO policy requires that all discharge summaries are completed within thirty (30) days of discharge. Despite this correction, two (2) discharge summaries were still non-compliant with the 30 day policy.
On 6/29, during clinical supervision, Clinical staff members will be instructed on the use of the Electronic Health Record System to produce "Services Due" reports. At this same meeting, staff members will also be provided with copies of the discharge summary policy and the discharge summary form.
Ongoing compliance with this will be monitored by the Facility Director with "Services Due" Reports being generated for each clinician on a monthly basis (during the first full week of each month).
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