INITIAL COMMENTS
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This report is a result of an on-site licensure renewal, provisional license follow-up and methadone monitoring inspection conducted on November 15-17, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on review of personnel records, the Staffing Requirements Facility Summary Report, conversation with staff and direct observation, the facility failed to have a facility director that meets both the educational and experience required for the position.
Employee #2, who was promoted to facility director on March 24, 2022, did not meet the educational and program planning requirements for the position.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Regional Director will remain as the Clinic Director in accordance to §704.5(c).
The Clinic Director shall continue to maintain oversight and operations to the facility in accordance with §704.5 standards.
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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 the review of fire drill logs from December 2021 - October 2022, the facility failed to conduct an unannounced fire drill in January, February, March, May, June, September and October 2022.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Health and Safety Liaison will continue to conduct, at minimum, one fire drill per month. The fire drills will be documented using the designated emergency drill form which includes all required elements specified in the regulation.
The CTC Director will monitor compliance in this area by reviewing and signing each drill report monthly to ensure a fire drill was conducted.
This will be reviewed with staff during the Monthly Staff meeting on January 10, 2023.
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709.29 (a) LICENSURE Retention of client records
§ 709.29. Retention of client records.
(a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
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Observations
During the on-site inspection, the facility failed to have patient records readily accessible as the wait time to gain access for the Department staff was two hours and 45 minutes.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will review finding with IT department and ensure a SMART login is created for all unannounced visits to ensure access is readily available upon arrival. CTC Director will work to have this corrected by 3/30/23 |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of client records, the facility failed to provide written authentication for verbal orders within 3 business days from the time the order was given in five records reviewed. In addition, verbal orders for the client's initial dose as not ordered by a physician in four records reviewed.
Client #2 was admitted on December 7, 2021 and was still active at the time of the inspection. A December 23, 2021 verbal order was not authenticated until December 30, 2021. In addition, the client's initial dose order on December 7, 2021 was ordered by a mid-level practitioner.
Client #3 was admitted on January 19, 2019 and was still active at the time of the inspection. A March 14, 2022 verbal order was not authenticated until March 19, 2022.
Client #4 was admitted on June 21, 2022 and was still active at the time of the inspection. Three verbal orders dated June 24, 2022, July 18, 2022 and July 25, 2022 were authenticated on June 30, 2022, July 31, 2022 and July 31, 2022, respectfully. In addition, the client's initial dose order on June 22, 2022 was ordered by a mid-level practitioner.
Client #6 was admitted on October 17, 2012 and discharged on June 21, 2022. A January 13, 2022 verbal order was not authenticated until January 20, 2022.
Client #7 was admitted on May 24, 2022 and was still active at the time of the inspection. A July 25, 2022 verbal order was not authenticated until July 31, 2022. In addition, the client's initial dose order on May 25, 2022 was ordered by a mid-level practitioner.
Client #10 was admitted on November 16, 2022 and was still active at the time of the inspection. The client's initial dose on November 16, 2022 was ordered by a mid-level practitioner.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
CTC Director will submit an I.T. ticket to ensure counter signatures are placed on all orders to signify written authentication. All orders will be signed by the physician within 3 business days. This will be monitored by the Nursing Supervisor and Program director by utilizing the Signature Pending review tab in SMART. The CN and CD will review the tab weekly to ensure compliance.
CD will meet with nursing and prescribers to discuss the improvement plan by 1/12/23.
The physician will be contacted for all admission orders prior to any patient beginning medication treatment. The order will then be authenticated in writing within three business days and will be monitored weekly by the CD and NS via the Signature Pending tab in the SMART EMR.
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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 the review of client records, the facility failed to notify the client in writing of a decision to involuntarily terminate the client's treatment in one out of one applicable record reviewed.
Client #1 was admitted on November 4, 2016 and discharged on December 8, 2021.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director and Clinical Supervisor will ensure a notification of treatment letter is completed and given or mailed according to the involuntary termination policy.
CTC Director will review at Staff meeting on 1/10/23 to ensure all staff are utilizing the termination letter appropriately.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client records, the facility failed to file an unusual incident report within 3 business days following an incident on February 28, 2022 involving presence of ambulance personnel. At the time of the inspection, no unusual incident report had been filed for this incident.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will review with the health and Safety Liaison by 1/10/23 to ensure any incident is reported to the CTC Director.
The CTC Director will ensure any unusual incidents are reported to the Department within the 3 business days as requested.
The CTC Director will review with Clinical Supervisor and Charge Nurse at Staff meeting on 1/10/23.
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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to document an emergency contact in one out of ten records reviewed.
Client #3 was admitted on January 19, 2019 and was still active at the time of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will review with Clinical supervisor to continue to run SMART reports monthly to ensure all Emergency contacts are updated yearly.
The CS will monitor emergency contact releases during her monthly Quality Record Reviews. Additionally, the CD will monitor quarterly via the Chart to Charge process.
The CTC Director will review the importance of emergency contact releases with all staff at monthly meeting on 1/10/23.
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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 conduct a face-to-face determination prior to administering first dose in one out of five applicable records reviewed.
Client #4 was admitted on June 21, 2022 and was still active at the time of the inspection. The patient's initial dose was administered on June 22, 2022 and the face-to-face determination occurred on June 24, 2022.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Prior to admission all prescribers will complete the DSM diagnostic criteria located in the initial history and physical. This will be monitored by the CS during monthly quality record reviews and spot checked by the CD during the Chart to Charge review process. Completion of the physical will also be checked by the nursing staff prior to initial dosing. This will be reviewed in the all staff meeting on 1/10/23. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to document monthly random urinalysis in one out of nine applicable records.
Client #9 was admitted on October 24, 2018 and was still active at the time of the inspection. The monthly urinalysis on July 13, 2022 did have any results listed in the patient's record.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will review with Clinical Supervisor and Charge Nurse on 1/10/23 to ensure all results are posted in charts.
Charge nurse will continue to run SMART reports daily to ensure all results are transferred from lab to SMART appropriately. Should lags in UA results be found, the charge nurse will contact the lab directly to determine the reason. This will be documented in management meeting minutes.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on observation of medication administration, the facility failed to follow their policy and procedures manual in regard to identifying patient. Section 6.1 of the policy and procedures manual states the dispensing nurse will verify the current dose order with the patient prior to administering medication. Verification was not completed on one patient.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will review with Charge Nurse to ensure identity of patients are verified with 3 out of the 5 patient identifiers as a current dose is a must for each patient.
CTC Director will review at Staff meeting on 1/10/23.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on the review of patient records, the facility failed to provide 2.5 hours of psychotherapy per month, 1 hour of which shall be individual psychotherapy in three out of four applicable records.
Patient #2 was admitted on December 7, 2021 and was still active at the time of the inspection. In August and October 2022, the patient only received 30 minutes of individual therapy each month. In September 2022, the patient received a total of 1.5 hours of therapy, of which only 30 minutes was individual therapy.
Patient #7 was admitted on May 24, 2022 and was still active at the time of the inspection. In August 2022, the patient did not receive any therapy hours. Documentation showed three 30-minute no show appointments for individual therapy. In September 2022, the patient received a total of one hour of therapy. In October 2022, the patient received a total of 1 hour and 15 minutes of therapy with two 30-minute no show appointments.
Patient #8 was admitted on October 4, 2021 and was still active at the time of the inspection. In August 2022, the patient received a total of one hour of therapy.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will review with Clinical supervisor 1/10/23 to continue with Monthly Supervision with each counselor which should include reviewing the requirements for counseling services needed for each staff members case load.
Clinical supervisor will continue to run SMART reports Monthly to review number of hours to ensure that each patient is adhering to the clinical requirements under 715.19 (I).
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715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to transfer the patient's information to their new facility in one out of one applicable record.
Patient #1 was admitted on November 4, 2016 and discharged on December 8, 2021.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will review with all staff to ensure all transfer records are sent that is needed by their new facility. Director will review during monthly staff meeting on 1/10/23.
The Clinic Supervisor will review monthly on the quality records review for transfers and discharges to ensure patients records are sent to the new facility. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to notify the patient's previous facility of their admission to the facility in one out of one applicable record.
Client #7 was admitted on May 24, 2022 and was still active at the time of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will review with Clinical Supervisor and Charge nurse to ensure the transfer form is sent to the patient's previous facility on admission dat. Director will review on 1/10/23 at managers meeting.
The charge nurse will review monthly on the quality records review to ensure the transfer notification was sent. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to conduct an annual physical examination within the regulatory timeframe in one out of two applicable records reviewed.
Client #8 was admitted on October 4, 2021 and was still active at the time of the inspection. The annual physical exam was due on October 4, 2022; however, it was completed on October 18, 2022.
The finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the March 25, 2022 licensing inspection.
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Plan of Correction
The CTC Director will review with medical team to make certain that all annual physical examinations are completed by annual date.
The Charge nurse and Clinical supervisor will continue to run SMART reports monthly to ensure all annuals are scheduled and completed within time frame.
The CTC Director will review with all staff at Monthly Staff meeting on 1/10/23.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document an annual evaluation within the regulatory timeframe in one out of two applicable records reviewed.
Client #8 was admitted on October 4, 2021 and was still active at the time of the inspection. The annual evaluation was due on October 4, 2022; however, it was completed on October 28, 2022.
The finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the November 18, 2021 and March 25, 2022 licensing inspections.
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Plan of Correction
The CTC Director will review with Clinical Supervisor to make certain that all annual evaluations are completed by annual date.
The Clinical Supervisor will continue to run SMART reports monthly to ensure all annuals are scheduled and completed within time frame by monitoring the Services Due Report.
The CTC Director will review with all staff at Monthly Staff meeting on 1/10/23.
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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 client records, the facility failed to document a psychosocial evaluation in two out of three applicable records.
Client # 2 was admitted on December 7, 2021 and was still active at the time of the inspection.
Client #4 was admitted on June 21, 2022 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CTC Director will review with Clinical Supervisor to make certain that all psychosocial evaluations are completed within policy timeframe.
The Clinical Supervisor will continue to run SMART reports and complete Quality Record reviews monthly to ensure all psychosocial evaluations are completed within time frame.
The CTC Director will review with all staff at Monthly Staff meeting on 1/10/23.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in five out of seven applicable records.
Client #2 was admitted on December 7, 2021 and was still active at the time of the inspection. A treatment plan update was completed on June 3, 2022 and the next update was due no later than August 3, 2022; however, it was not completed until August 9, 2022.
Client #3 was admitted on January 19, 2019 and was still active at the time of the inspection. A treatment plan update was completed on May 12, 2022 and the next update was due no later than September 12, 2022 due to an exception granted by the Department; however, the update was completed on September 21, 2022.
Client #6 was admitted on October 17, 2012 and discharged on June 21, 2022. A treatment plan update was completed on October 15, 2021 and the next update was due no later than February 15, 2022 due to an exception granted by the Department; however, the update was completed on February 22, 2022.
Client #7 was admitted on May 24, 2022 and was still active at the time of the inspection. A treatment plan update was completed on September 12, 2022 and the next update was due no later than November 12, 2022; however, there was no documentation of an update at the time of the inspection.
Client #8 was admitted on October 4, 2021 and was still active at the time of the inspection. A treatment plan was completed on November 12, 2021 and an update was due no later than January 12, 2022; however, it was not completed until January 17, 2022. In addition, the next update was due on March 17, 2022; however, it was not completed until March 21, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will review with Clinical Supervisor that all treatment plans need reviewed and updated at least every 60 days.
The Clinical Supervisor will continue to run SMART Services Due reports to monitor treatment plans that are due. The clinical Supervisor will also review with counseling staff at weekly supervision meetings to ensure if changes need updated in the treatment plans.
The CTC Director will review with all staff at Monthly Staff meeting on 1/10/23.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in five out of six applicable records reviewed.
Client #2 was admitted on December 7, 2021 and was still active at the time of the inspection. A treatment plan dated June 3, 2022 and August 9, 2022 indicated individual therapy 2.5 hours per month with no group sessions required. An October 6, 2022 treatment plan indicated individual therapy one time per month and group sessions twice a month. In August and September 2022, the client received 30 minutes of individual therapy each month.
Client #4 was admitted on June 21, 2022 and was still active at the time of the inspection. A treatment plan dated July 15, 2022 indicated 2.5 hours per month of individual therapy and group sessions one time per month. In August 2022, the client had no sessions with three 30-minute no show individual session appointments. In September 2022, the client had one hour of individual sessions with two 30-minute no show individual session appointments. In October 2022, the client had 30 minutes of individual session and one 30-minute no show appointment.
Client #7 was admitted on May 24, 2022 and was still active at the time of the inspection. A June 23, 2022 treatment plan indicated 2.5 hours per month of individual sessions with no group sessions required. In August 2022, the client received no sessions and had three 30-minute no show individual session appointments. In September 2022, the client received one hour of individual sessions. In October 2022, the client received one hour and 15 minutes of individual sessions with two 30-minute no show individual session appointments.
Client #8 was admitted on October 4, 2021 and was still active at the time of the inspection. A treatment plan dated July 25, 2022 indicated 2.5 hours per month of individual sessions with no group session requirement. A September 12, 2022 treatment plan indicated 2.5 hours of individual therapy and one hour of group therapy per month. In August 2022, the client received one hour of individual therapy. In October 2022, the client did not receive any group therapy sessions.
Client #9 was admitted on October 24, 2018 and was still active at the time of the inspection. A June 22, 2022 treatment plan indicated one hour of individual sessions per month. In August and September 2022, the client received zero hours of individual therapy each month.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the November 18, 2021 and March 25, 2022 licensing inspection.
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Plan of Correction
The CTC Director will review with Clinical Supervisor to ensure counseling services are completed according to treatment plan per 709.92(c).
CTC Director and Clinical Supervisor will continue to run SMART reports and reviewing non-compliant clients on report.
Clinical Supervisor will continue counselor supervision sessions weekly to review client non-compliance with treatment plan.
Proper documentation of client no-shows and cancellations will be reviewed on 1/10/23 with all staff at the monthly staff meeting.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on the review of patient records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction was submitted to the Department for inspections occurring on November 18, 2021, March 25, 2022 and November 17, 2022, addressing the requirement to provide counseling services according to the individual's treatment plan.
A plan of correction was submitted to the Department for inspections occurring on November 18, 2021, March 25, 2022 and November 17, 2022, addressing the requirement to document an annual reevaluation within the regulatory timeframe.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will review counseling services and annual evaluations with Management team weekly to ensure these requirements are met to comply with 709.92 and 715.23. The CTC Director will utilize Direct Services Report to monitor. The CTC Director will discuss with the management team on 1/10/23. |