INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 26-28, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. 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.
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Plan of Correction
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704.5(b) LICENSURE Clinical Supervisor
704.5. Qualifications for the positions of project director and facility director.
(b) If the facility does not have a clinical supervisor on staff, clinical responsibilities shall be addressed in one of the following ways:
(1) A facility director who has direct responsibility for clinical services shall meet the qualifications in at least one of the paragraphs of 704.7 (b) (relating to qualifications for the position of counselor).
(2) If the facility director does not meet counselor qualifications and the facility employs less than eight counselors, a lead counselor or part-time clinical supervisor shall be appointed.
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Observations
A licensing renewal inspection was conducted on November 26-28, 2018. At the time of the inspection, the facility director had direct responsibility for the clinical services. The facility did not have a clinical supervisor on staff and a lead counselor was not appointed. The facility director, hired by the project on October 8, 2018, did not meet the counselor qualifications required for the direct oversight of clinical services.
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
In order to meet the Clinical Supervision regulation, effective January 13, 2019, two Lead Counselors have been appointed to the clinical department.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility's fire drill records were reviewed on November 28, 2018, for the period of January 2018 - October 2018. The facility failed to record the number of people in the facility during fire drills conducted on the following dates:
-February 7, 2018
-March 27, 2018
-April 16, 2018
-May 25, 2018
-June 14, 2018
-July 6, 2018
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The corrected template, requiring documentation of the number of staff in attendance has already been put into use effective August 2018.
Facility Director will ensure continued use of appropriate and updated form.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Six personnel records were reviewed for the licensing renewal inspection conducted on November 26-28, 2018. The facility failed to provide documentation of an annual performance evaluation for employee record # 5.
Employee # 5 was hired by the facility on October 2, 2017, as a counselor. An annual performance evaluation was not documented in the employee's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
December 10, 2018, Facility Director notified DDAP Inspector, via email, of the employees Annual Review completion within the appropriate time frame. Annual Review was completed on September 20, 2018 and located within the employee's electronic personnel file.
Plan of correction: Facility Director to monitor and complete all personnel evaluations in the appropriate time frames. This employee file has been updated with most recent evaluation
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
A physical plant inspection was conducted on November 28, 2018, during the licensing renewal inspection. During this inspection, a box of client records was found in an unlocked storage room.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Immediately following inspection the room was locked and all client records have since been relocated to the allocated file room.
Facility Director to ensure all client records are stored and locked in the appropriate file room. Supervisory follow-up with Administrative Support staff, Nursing Staff and Clinical Staff completed individually immediately following DDAP audit and reviewed during December staff meeting.
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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.
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Observations
The facility failed to provide documentation of an informed and voluntary consent in patient record # 8.
Patient # 8 was admitted on October 30, 2018 and was still an active patient at the time of the inspection. A consent to release form to an insurance agency was expired and was not renewed in the patient record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director reviewed forms completion process with staff to ensure that an exact date of expiration is listed for each release and not, "One Year", to ensure the forms do not expire prematurely.
Facility Director and Team Leads will continue to monitor for adherence through monthly chart audits. Client #8 record has been corrected effective 11/28/2018.
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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
Physician time sheets and weekly census reports were reviewed on November 28, 2018, for the time period of July 2018 - November 2018. The facility failed to provide sufficient onsite physician hours for the following weeks:
For the week of July 29, 2018, the reported patient census was 201. The facility was required to provide at least 20.1 onsite physician hours. There were 16 onsite physician hours documented for this week.
For the week of August 12, 2018, the reported patient census was 203. The facility was required to provide at least 20.3 onsite physician hours. There were 16 onsite physician hours documented for this week.
For the week of August 26, 2018, the reported patient census was 202. The facility was required to provide at least 20.2 onsite physician hours. There were 16 onsite physician hours documented for this week.
For the week of September 9, 2018, the reported patient census was 206. The facility was required to provide at least 20.6 onsite physician hours. There were 14 onsite physician hours documented for this week.
For the week of September 16, 2018, the reported patient census was 202. The facility was required to provide at least 20.2 onsite physician hours. There were 12 onsite physician hours documented for this week.
For the week of September 23, 2018, the reported patient census was 207. The facility was required to provide at least 20.7 onsite physician hours. There were 16 onsite physician hours documented for this week.
For the week of October 28, 2018, the reported patient census was 213. The facility was required to provide at least 21.3 onsite physician hours. There were 16 onsite physician hours documented for this week.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation. The facility was cited for non-compliance of this regulation during the previous licensing renewal inspection completed on December 13, 2017.
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Plan of Correction
It has been noted that the periods of time indicated do reflect a lapse in required physician coverage.
The on-boarding of a physician assistant in October 2018 alleviated this issue, with the exception of the week of October 28, 2018, when the physician assistant was not present. As discussed during the audit the facility is now in compliance with the regulation.
Facility Director will continue to monitor census to ensure compliance with the regulation and adjust physician/physician assistant hours appropriately.
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